X-' 



I) 












•i^' 



OBSTETRIC CLINIC 



A PEACTICAI COUIEIBUTIOS TO THE STUDY 



OBSTETRICS, AND THE DISEASES OF 
WOMEN AND CHILDREN. 



BY 

GEORGE T/ELLIOT, Jr., A.M., M.D., 

Professor of Obstetrics and the Diseases of Women and Children in the Bellevue Hospital Medical College 

Physician to Bellevue Hospital, and to the New York Lying-in Asylum ; Consulting Physician to the 

Nursery and Child's Hospital; Consulting Surgeon to the State Women's Hospital; 

Corresponding Member of the Edinburgh Obstetrical Society, and of the 

Royal Academy of Havana ; Fellow of the New York Academy 

of Medicine ; Member of the County Medical Society, 

of the Pathological Society, etc. 



" Plus on s'eleve, plus rhorizon s'etend.' 



o< vv 



^ NEW YORK: 
D. APPLETON AND COMPANY^ 

443 & 445 BEOADWAY. 

1868. 

V 



yN\ 







Enteeed, according to Act of Congress, in the year 1867, by 
D. APPLETON & CO., 

In the Clerk's Office of tlie District Court of the United States for the Southern District 
of New York. 



i^/1 



THIS VOLUME 

IS RESPECTFULLY INSCRIBED 

TO THOSE GENTLEMEN IN WHOM IT MAY REVIVE 

PLEASANT CLINICAL RECOLLECTIONS. 



»i 



I 



PREFACE 



DuEixa a service of fourteen years in Bellevue Hospital, 
it has been my constant endeavor, by clinical instruction, 
to make my advantages available for others ; and I have 
pubhshed many cases which interested me most deeply, and 
especially such as terminated unfortunately, both in medical 
journals and in papers read before the 'New York Academy 
of Medicine and the State Medical Society. 

At the commencement of my service in Bellevue during, 
April and May, 1867, 1 determined that the most interesting 
cases should serve as the basis for a volume, in which should 
be interwoven the substance of such clinical remarks as were 
then made to the class in attendance, with such other prac- 
tical hints as might naturally suggest themselves during the 
preparation of the work ; but that the great aim of the book 
should be, to illustrate my views with the cases which had 
accumulated on my hands, or had been published in journals 
now discontinued, and not very available for reference. 

Such a course has allowed me to adopt the style and 
phraseology of a lecture whenever the character and extent 
of the subject permitted; and has led me to place those cases 
treated in the designated service, at the commencement of 
the chapters, where they serve as texts. 



VI 



PREFACE. 



The cases thus collected represent faithfullj the difficul- 
ties, anxieties, and disappointments inseparable from the 
practice of obstetrics, as well as some of the successes for 
wliicb we are entitled to hope in these arduous and respon- 
sible tasks. Thej illustrate debatable and elective methods 
of treatment, and may therefore contribute to the establish- 
ment of laws as yet undecided. They supply a large num- 
ber of facts in elucidation of the relations of albuminuria to 
pregnancy, and demonstrate alike the unexpected difficulties 
and the unexpected ease which may mark the performance 
of obstetric operations. 

"While available, therefore, for critical analysis, their ful- 
ness of detail may render them of value for the student and 
the practitioner. The clinical remarks represent succinctly, 
but fully^ my own views of practice. For the facilitation 
of reference, a very copious and carefully prepared index has 
been added. 

I have also taken this opportunity to republish the results 
of the study of kyestein by the late Dr. Henry Yan Arsdale 
and myself, as the paper has not been so accessible to the 
profession as we had desired ; and as the lapse of time and 
further observations have convinced me of the correctness 
of our conclusions. 

Finally, the work is presented as a partial discharge of the 
debt due to the profession by all who enjoy hospital advan- 
tages ; and in grateful recognition of the benefits which the 
author has derived from the recorded experience of others. 



CONTENTS 



CHAPTER I. 



EELATIONS OF ALBUMESTUEIA TO PEEGNANOY. 

Case: Bright's Disease. — Case: Induction of labor for albuminuria, and dimi- 
nution of the urine. — Puerperal albuminuria and eclampsia. — Frequency 
of albuminuria in the puerperal state. — Relations of albuminuria to preg- 
nancy. — Case: Cardiac disease; albuminuria; oedema of lungs; forceps; 
suppression of urine. — Case : Albuminuria ; uterine fibrous tumors ; 
rigid OS; douche; incision of cervix; forceps. — Case: Albuminuria; 
miscarriage; great jactitation. — Case: Puerperal eclampsia; albuminu- 
ria ; manual dilatation of cervix ; douche ; Barnes's dilator. — Physiognomy 
in albuminuria. — Case: Bright's Disease. — Case: Albuminuria; eclamp- 
sia; forceps. 1 



CHAPTER II. 



PEOPHTLAXIS OP PIJEEPEEAL ECLAMPSIA.- 
OONVULSIONS. 



-YAEIETIES OP PUEEPEEAL 



Prophylaxis of puerperal eclampsia. — Case: Puerperal eclampsia; profuse 
salivation from a mercurial purge. — ^Purgatives ; diaphoretics ; acids ; diet. 
— Case: Albuminuria; puerperal eclampsia. — Induction of labor as a 
• prophylaxis. — Case: Puerperal eclampsia; induction of labor; Barnes's 
dilators; forceps. — Case: Albuminuria in pregnancy. — Case: Puerperal 
eclampsia; induction of labor. — Case: Albuminuria and eclampsia in the 
first confinement ; albuminuria and induction of labor in the second by the 
douche. — Case : Puerperal eclampsia ; induction of labor ; Barnes's dilators ; 
douche; forceps. — Varieties of puerperal convulsions. — Case: Puerperal 
convulsions; no renal disease; consciousness not abolished; douche. — 
Case: Hysterical convulsions and hemiplegia. — Case: Poisonous efiects of 
an infusion of stramonium-leaves, injected in the rectum. . . .33 



VIU 



CONTENTS. 



CHAPTER III. 

OHLOEOFOEM AND TEXESECTIOX IX PUEEPEEAL ECLAMPSIA. 

Chloroform in puerperal eclampsia. — Case: Alarming symptoms from chloroform 
in a natural labor. — Case: Alarming symptoms from sulphuric ether in an 
operation for urethro-vaginal fistula. — Chloroform in cardiac disease and 
syncope. — Case: Syncope after labor, and subsequent history. — Case: 
Powerless labor; delay; cardiac murmur; ether; forceps. — Case: Amy- 
lene. — Venesection. — Case: Puerperal eclampsia ; venesection. — Case: Puer- 
peral eclampsia; forceps. — Case: Puerperal eclampsia; forceps. — Case: 
Puerperal eclampsia; no albumen; forceps. — Case: Puerperal eclampsia; 
venesection; cups; chloroform. — Case: Puerperal eclampsia; venesection; 
cathartics; forceps. — Case: Puerperal eclampsia; chloroform; cups; for- 
ceps. — Case: Puerperal eclampsia; cups; chloroform. — Case: Twins; 
eclampsia; chloroform; purgatives; cups. — Case: Puerperal eclampsia; 
mania. — Case: Puerperal eclampsia; chloroform; cathartics; emetics; 
venesection. — Case: Puerperal eclampsia; no albumen. — Case: Puerperal 
eclampsia; forceps; normal dilatation. — Case: Puerperal eclampsia. — 
Case: Albuminuria; intra-uterine hydrocenhalus. — Case: Bright's disease; 
puerperal eclampsia; chloroform; Barnes's dilators. — Case: Albuminuria; 
eclampsia; death before dehvery. — Case: Albuminuria; eclampsia; death 
from apoplectic clot with atheromatous degeneration of vessels. — Case. 
Albuminuria; eclampsia. — Case: Albuminuria; induction of labor ; mania; 
subsequent history. — Case: Albuminuria; eclampsia; induction of labor. — 
Case : Albuminuria ; eclampsia ; induction of labor ; craniotomy. . 63 



CHAPTER IV. 

RELATIONS OF EPILEPSY TO THE PUEEPEEAL STATE. — PUEEPEEAL MANIA. 

Case: Epilepsy; puerperal mania; subsequent death of child in epileptiform 
convulsions. — Patients with epilepsy not specially liable to attacks during 
labor. — Case: Epilepsy; venesection; confinement. — Albuminuria in epi- 
lepsy. — Puerperal mania. — Danger to the child from its mother. — Progno- 
sis; hereditary predisposition. — ^Asylums. — Nutrition. — Necessity for tact 
and presence of mind in the management of these cases. — Urine and faeces. 
— Summary of treatment. — Case: Puerperal mania. — Case: Puerperal 
mania. — Case ; Puerperal mania. — Case ; Puerperal mania. . . 127 



CHAPTER Y. 

ANTE-PAETUM HEMOEEHAGE. 



Case : Repeated and unavoidable hemorrhages during pregnancy ; induction of 
labor. — Reasons for deciding on an elective operation. — Interference and 



CONTENTS. 



IX 



non-interference may be equally successful in certain cases .^ Case ; Placenta 
prsevia. — Case: Placenta prsevia; tampon and two-finger version. — Case: 
Forceps for ante-partum hemorrhage. — Case: Placenta praevia; Barnes's 
dilators ; forceps. — ^Why prompt measures will not always be resorted to in 
time. — Tampon. — Case: Placenta praevia; presentation of foot and hand; 
prolapse of funis ; adherent placenta. — Importance of distinguishing between 
the dilated and the dilatable cervix 140 



CHAPTER YI. 



INDUCTION OF LABOE. 



Methods for dilating the os and cervix uteri. — Douche. — Case: Induction 
of labor with the douche for deformity of brim. — Case: Induction of 
labor with the douche for deformity of the pelvis, and irremediable anterior 
obliquity of the uterus. — Case: Induction of labor with the douche for 
uncontrollable vomiting in pregnancy. — Douche in rigid os uteri. — Case: 
Dilatation of rigid os by douche. — Case: Dilatation of rigid os by douche. — 
Barnes's dilators. — Case: Kigid os treated by Barnes's dilators, with imme- 
diate contraction of the cervix when these were withdrawn. — Case: Induc- 
tion of labor with Barnes's dilators for hemiplegia, etc. — Sponge, or other 
tents. — Methods for disinfecting these. — Manual dilatation. — Ca^e: Rigid os ; 
douche ; manual dilatation ; forceps. — Methods for inducing uterine contrac- 
tion. — Case: Induction of labor for deformity; unusual difficulty in bringing 
on contraction. — Case : Previous labor of this patient. — The introduction of 
a catheter between the membranes and the uterus. — Case: Induction of 
labor for deformity, with douche, dilators, and catheter. — Case: Induction 
of labor for deformity, with douche, dilators, and catheter. — Separation of 
membranes. — Electric and galvanic currents in the induction of uterine 
contractions ; in amenorrhcea, and as a galactogogue. — Puncture of the 
membranes. — Medicines for inducing uterine contractions. — Case: Tedious 
labor; ergot; forceps. — Case: Deformity of pelvis ; ergot; forceps. . 15*7 



CHAPTER VII. 



EFFECT OF THE TONIC CIECTJLAE CONTEACTION OF A BAND OF TJTEEINE 
MTISCIJLAE FIBEES ON LABOE. — BEOW AND FACE PEESENTATIONS. — EUP- 
TUEE OF UTEEUS. 

Effect of the tonic circular contraction of a band of uterine muscular fibres on 
labor. — Case: Brow presentation; chloroform, forceps, version, the per- 
forator, crotchet, and craniotomy forceps having failed to overcome this 
obstacle, the patient was delivered with the cephalotribe. — Case: Brow and 
face presentation ; powerless labor with circular band of contracted uterine 
fibres ; chloroform ; lever ; forceps ; partial version ; perforator. — Case : 



CONTENTS. 

Contracted conjugate ; tonic circular contraction of uterine fibres ; failure 
of forceps, twice applied after an interval of three hours ; chloroform ; im- 
possibility of version; craniotomy. — Case: Forceps; tendinous band in 
vagina; peritonitis. — Remarks on brow and face presentations. — Case: 
Forehead presentation converted by conjoined manipulation into that of the 
vertex. — Case: Rupture of uterus; presentation of brow, hand, and funis; 
delivery by version and crotchet; recovery of mother. — Case: Rupture of 
uterus; version; brow presentation; anterior uterine obliquity. — Case: 
Rupture of uterus; patient died before delivery. — Further remarks on brow 
presentations. — Case: Right mento-iliac presentation; death of child, and 
then craniotomy. — Case: Shoulder and arm presentation; cephalic version 
by external manipulation, aided by vectis and forceps, ineffectual to flex the 
head; podalic version and perforator. — Management of frank face presenta- 
tions. — Case: Locked face presentation; effect of manipulation; forceps; 
perforator. — Anecdote of face presentation. — Chin posteriorly. — Case: Face 
presentation; chin to right sacro-iliac synchondrosis; rotation of chin to 
pubes with forceps. — Further illustrations of the uses of the hand in 
facilitating labor. — Case: Twins in a pelvis with conjugate of three and 
a half inches ; risk of locking of heads prevented by manipulation. — Ben- 
jamin Pugh's recommendations in the delivery of the head in breech pre- 
sentations. .... 197 



CHAPTER YIII. 

POST-PAETIDI HEMOEEHAGE. 

Case: Post-partum hemorrhage. — Remarks on post-partum hemorrhage. — "Why 
tordc uterine contraction is desirable. — Treatment. — Ergot. — Hand in utero. 
— Cold. — Manipulation of the uterus. — Case : Foot, hand, and funis presenta- 
tion of second twin ; commencing inversion of the uterus rectified by manip- 
ulation. — Undue elevation of the fundus uteri a sign of danger. — Its causes. 
— Fatal post-partum hemorrhage does not necessarily flow out of the vagina. 
— Case: Albuminuria; post-partum convulsions; post-partum hemorrhage. 
— Case : Post-partum hemorrhage. — ^Why the placenta and membranes 
should be carefully examined. — How soon delivered. — How removed. — 
Indications for an ansesthetic. — Hemorrhage when the uterus remains con- 
tracted. — Position of patient. — Arteries. — Warmth. — Restoratives. — Ene- 
mata. — Anodynes. — The Dublin School. — Case: Tedious labor; forceps; 
novel views of uterine hemorrhage. — Transfusion. — Anaemia. — Predisposi- 
tion to future post-partum hemorrhages. — Ergot for multiparas after labor. — 
Subsequent hemorrhages. — Case: Forceps; puerperal fever; bronchitis; 
death from uterine hemorrhage eleven and a half days after delivery. — Ob- 
stetric binder 223 



CONTENTS. XI 

CHAPTER IX. 

OBSTETEIC OPEEATIO^'S IX DEFORMED PELYES. 

Case: Contracted conjugate diameter in a primipara; forceps. — Case: Con- 
tracted conjugate diameter in a primipara; forceps. — Case: Transverse 
presentation in a contracted conjugate diameter ; cephalic version ; perfora- 
tion ; cranioclast ; death of child from premature respiration. — Case : Kachi- 
tis ; contracted outlet ; forceps. — Increasing frequency of pelvic deformity 
in this country. — ^The same deformity admits of varying results in successive 
pregnancies. — Case: History of successive pregnancies in a patient with 
contracted conjugate. — Can these measurements be accurately made? — 
Case: Deformity of pelvis; albuminuria; forceps and version failing, deliv- 
ery effected by craniotomy and the cranioclast ; accurate measurement of 
pelvis by Earle's pelvimeter; pneunjonia and metritis. — Pelvimetry. — DiflS.- 
culty in estimating the size of the foetal head. — Remarks on the ulcerative 
perforation of the uterus and bladder in Case No. 94. — Case: Deformed 
pelvis ; forceps ; death from perforation of the uterus by sacral promontory. 
— Case: Contracted pelvic brim; forceps; vesico-vaginal fistula. — Case: 
Arrest of head by promontory of sacrum; forceps. — Case: Forceps for con- 
tracted brim. — Case: Forceps in superior strait. — Case: Rigid os and 
lingering first stage; douche; forceps within the brim. — Case: Forceps for 
febrile symptoms in an epidemic of puerperal fever. — Case: Forceps for 
delay. — The proper time for operating in cases of delayed or obstructed 
labor. — Delivery of the head through the pelvic brim with forceps. — If it be 
even possible that the child is living. — Henry VIII. and Napoleon I. — This 
operation sums up all the difficulties with forceps. — Room for instruments 
may be obtained by pushing up the head, and the head may be steadied 
against the brim. — Case : Forceps above the brim. — Case: Pelvic presenta- 
tion in an undersized pelvis ; room singularly obtained for forceps. — The 
head may be made to engage by external manipulation. — Case : Forceps in 
an undersized brim. — Case: Occiput pressed against the linea ilio-pectinea 
and rotating from the left acetabulum to near the right sacro-iliac synchon- 
drosis ; made to engage by manipulation. — Case: Ante-partum hemorrhage; 
rotation of head before it engaged in the brim ; forehead presentation con- 
verted by the head into that of occipital ; previous pressure of the head 
into the brim by the hand. — The head may be made to engage in the brim 
by altering the mother's position,— Case.- Movement of descent brought 
about by changing the position of the mother 242 

CHAPTER X. 

CHOICE, USES, AND APPLICATIONS OF FOECEPS (CONTINUED). 

Introduction of forceps within the cervix uteri. — Case: Puerperal eclampsia; 
albuminuria; douche; forceps within the cervix. — Case: Eclampsia; 



Xll 



CONTENTS. 



douche; forceps delivery through a rooderately dilated cervix. — Case: 
Eclampsia in the eighth month; extraordinary family history ; rigid cerrix; 
douche; dilators; forceps. — Case: Forceps for arrest of head in superior 
strait from extension of head ; manual eflPorts at forceps imavailing ; appli- 
cation of forceps; laceration of cervix. — Case: Rupture of uterus at its 
vaginal attachment; forceps. — Incision of cervix. — Case: Eclampsia; ab- 
solutely unyielding os and cervix ; douche ; incision ; forceps. — Application 
of forceps in the brim. — In contracted conjugate the head transverse, and 
seized obHquely. — Case: Delayed labor; forceps and conversion of a right 
occipito-posterior position ; facial paralysis of child, and its recovery after 
convulsions. — Head seized in one of its oblique diameters. — Choice and uses 
of forceps. — Best use is that of a tractor. — Case : Forceps. — Case : Forceps ; 
perforator. — Case: Illustrative of great tractive force ; forceps; perforator. 
— Case : Powerless labor with rigidity ; ergot and forceps. — Case : Forceps ; 
impacted head; perforator. — Case: Forceps and laceration of vagina; sub- 
sequent application. — Case: Forceps; tedious labor from rigidity ; advan- 
tage of touching the head and forceps blades through the rectum during 
dehvery. — Case: Forceps for delay; still-born child; death of child and 
diflSculty in delivery believed to have been due to the encircling of the neck 
by the funis. — Application of the anterior blade.- — Position of the patient in 
forceps and operations. — Case: Forceps for delay ; cord tightly around the 
neck 287 



CHAPTER XI. 



EMBETOTOiTT. 



Preliminary considerations. — Difficulties attending the proof of the child's death. 
— Case: Forceps in lingering labor twice apphed. — Preliminary baptism. — 
Case: Breech presentation ; paralysis of sphincter ani coexisting with foetal 
heart-sounds; fillet after death of child. — Case: Forceps for exhaustion of 
mother ; approximation of ischiatic spines ; liquor amnii colored with meco- 
nium. — Case: Forceps for cessation of foetal heart-sounds. — Case: Pelvic 
presentation of a child weighing fourteen pounds ; remarkably small nates ; 
blunt-hook. — Case: Arm presentation'; cephahc version; child supposed to 
be dead ; no reflex movements ; foetal heart inaudible ; meconium present 
in great quantity in the discharges ; child subsequently bom ahve. — Case: 
Forceps for delay aud danger to child ; difficult auscultation. — Choice of 
instruments for embryotomy. — Perforator. — Cephalotribe. — Craniotomy. — 
Forceps. — Blunt-hook. — Introduction of the perforator. — Case: Perforation 
in a contracted conjugate. — Case: Contracted outlet; forceps; perforation. 
— Case: Forceps and perforator for deformity of brim. — Case: Arm in the 
vagina ; head above to the right ; child dead ; perforator ; brow had origi- 
nally presented. — Case: Eupture of uterus ; removal of placenta and yer- 
sion; perforator. — Case: Eclampsia in sixth or seventh month ; induction 



CONTENTS. 



Xlll 



of labor with douche; venesection; purgatives; delivery with a crotchet 
made of strong wire. — Ca^e: Fatty degeneration of foetus and placenta at 
term with history of previous labor. — Case: History of her previous labor. 
— Case: Twins — one linng, one dead; fatty degeneration of the latter's 
placenta 314 

CHAPTER XII. 



General considerations. — Case: Child dead; uterus distended by gases; ver- 
sion. — How to appreciate the position of the child by examining its 
hand. — Case: Version for transverse presentation of second twin. — 
Spontaneous expulsion. — Case: Spontaneous expulsion by cephalic ver- 
sion of the second twin presenting originally in a transverse position. 
— ^Dangers of version. — ^Yersion in deformed pelves. — Case: Twins; con- 
tracted conjugate ; vesico- vaginal fistula after the first labor, cured by Dr. 
Emmet; perforation of both twins in the second labor, the first pre- 
senting the breech and the second the head. — German experience in version 
as an elective operation in deformed pelves. — Case : Deformed pelvis ; 
dwarf; forceps; version. — Case: Deformity of the conjugate; forceps; 
version; perforation. — Case: Contraction of conjugate; forceps; version; 
perforation. — Case: Transverse presentation ; difficult version ; prolapse of 
funis. — Case: Presentation of nape of neck and shoulder in a contracted 
pelvis; version; blunt-hook. — Case: Oblique cranial presentation from left 
uterine obliquity ; forceps ; perforator. — Fracture of limbs in version, or in 
original pelvic presentation. — Case: Version for transverse presentation; 
fracture of arms; forceps. — Case: Forceps in occipito-posterior presenta- 
tion ; fracture of arm - . . . . 341 



CHAPTER XIII. 

INFLAMMATOET OOMPLIOATIONS IX THE SITEGIOAL TREATMENT OF THE 
DISEASES OF WOMEN. 

Risk of developing inflammatory complications in the surgical treatment of 
women. — Carbolic acid. — Case: Retroverted uterus, with ovaries in the 
cul-de-sac forbidding the use of a pessary. — Use of pessaries. — Case: Re- 
troversion of an hypertrophied uterus, with dangerous menorrhagia ; benefit 
from pessary. — Cases illustrative of the tolerance of pessaries improperly 
applied. — Case: Pelvic cellulitis not connected with the puerperal state; 
rapid recovery. — Open air and sunshine in the diseases of women. — Case: 
Cystitis, peri-cystitis, peri-nephritis in a virgin. — Case: Cellulitis of abdomi- 
nal wall in a virgin. — Remarks. — Case: Pelvic cellulitis and suppuration 
following sponge-tents. — Should pelvic abscesses from cellulitis always be 
opened ? — Case of pelvic abscess opening into the peritoneal cavity. — Pelvic 



XIV 



CONTENTS. 



fistulae. — Case: Abortion; metritis; hypertrophy of uterus. — The practice 
of abortion in this country. — Necessity for more hospitals, — Nursery and 
Child's Hospital. — Topical abstraction of blood from the uterus. — Beware 
of pregnancy 366 

CHAPTER XIY. 

CEETAIN CONDITION'S OF THE BLADDEE IN WOMEN. 

The clinical necessity for ascertaining the amount of urine which women may 
pass under certain conditions. — Case: Retention of menses by an imper- 
forate hymen ; operation. — Case : Dysuria from aphthous ulceration. — Case : 
Retroversion of impregnated uterus ; great accumulation of urine ; success- 
ful reposition and recovery. — Case: Unilocular ovarian cyst in the recto- 
vaginal cul-de-sac, complicating parturition and the cause of death. — Case : 
Retroversion of impregnated uterus. — Case : Retroversion of impregnated 
uterus. — Choice of catheter. 387 

CHAPTER XV. 

DANGEES FEOM COMPEESSION OF THE FUNIS. 

Case: Prolapse of funis. — Case: Pelvic presentation and arrest of head in the 
pelvis; compression of cord. — Case: Compression of cord in a cephahc 
presentation. — Case: Transverse position of head; cord around the neck of 
a still-born child. — Dangers to the child from compression of the funis, — 
Cord around neck. — Case: Forceps; six coils of funis around the neck, — 
Case : Forceps for danger to child. — Knots in the cord. — Pressure on the 
cord. — Case: Feet, funis, and head presentation. — Case: Head and funis; 
forceps. — Prolapse of the funis. — Case : Prolapse of funis ; interesting 
autopsy of child. — Case: Feet and funis presentation. — Forceps or version. 
— Case: Prolapse of funis ; forceps. — Case: Prolapse of funis in a breech 
presentation. — Case .* Prolapse of funis, — Conclusions, , . . 402 

CHAPTER XYI. 

EETEO-PHAETNGEAL ABSCESS. 

Case: Retro-pharyngeal abscess in an infant. — Case: Retro-pharyngeal abscess 
in a boy of seven months. — Remarks. — Case: Cellulitis (erysipelatous) in a 
new-born child. — Yalue of diet and hygiene in infancy. — Report on the 
pulse, weight, and respiration in infancy, with the influence of different 
kinds of alimentation on the state of health, by Dr. E. D. Hudson, Jr. 420 

CHAPTER XVII. 



Ktestein. 



433 



OBSTET-EIO OLIlsriO. 



CHAPTEE I. 



EELATIONS OF ALBTJMLN^HRIA TO PEEGI^"ANCT. 

Case: Bright's Disease. — Case: Induction of labor for albuminuria, and dimi' 
nution of the urine. — ^Puerperal albuminuria and eclampsia. — Frequency 
of albuminuria in the puerperal state. — Relations of albuminuria to preg- 
nancy. — Case : Cardiac disease ; albuminuria ; oedema of lungs ; forceps ; 
suppression of urine. — Case: Albuminuria; uterine fibrous tumors; 
rigid OS; douche; incision of cervix; forceps. — Case: Albuminuria; 
miscarriage; great jactitation. — Case: Puerperal eclampsia; albuminu- 
ria ; manual dilatation of cervix ; douche ; Barnes's dilator. — Physiognomy 
in albuminuria, — Case: Bright's Disease. — Case: Albuminuria; eclamp- 
sia; forceps. 



Case 1. BrigMs Disease', death four days after deliv- 
ery ; no convulsions: peritonitis. — J)r. D. McLean For- 
man^ Hou^e Surgeon. 

Beedget Conway, aged 21 ; Irisli ; unmarried ; admitted 
to Belle Yue, April 8, 1867, in the ninth month of her first 
pregnancy. It was ascertained that her feet had been 
swollen for the last three months, during which time she 
has suffered a great deal from vomiting and disturbance of 
the eyesight, principally from sudden temporary darkness. 
The urine is loaded with albumen (sp. grav. 1018), and con- 
tains large hyaline, epithelial, and granular casts. The 
abdomen did not appear to be larger than was natural for 
the time of gestation, but distinct peritoneal fluctuation was 
1 



an 



2 OBSTETKIC CLINIC. 

recognizable. Tlie foetal heart could not be heard, but by 
pressing the fluid from over the uterus the movements of the 
child in utero could be distinctly appreciated. The patient's 
face is pale, anaemic, not puffy. She was at once placed on 
a non-nitrogenous diet, her bowels moved at least twice a 
day by hydragogue cathartics, and a hot-air bath adminis- 
tered every second night. 

Labor commenced on the 15th, one week after admission, 
and was natural in every respect. Head presentation. R. 
O. A. 1st stage, eleven hours ; 2d, three and a half; 3d, five 
minutes. Male child ; weight, seven and one-quarter pounds. 
Throughout the labor the pains were feeble, and the woman 
complained greatly, both with each contraction and when- 
ever the hand was laid on the abdomen. 

ITth. — She has done well since her confinement. To- 
day her face is markedly puffy. There is a free secretion 
of urine. Ordered hot-air baths, saline cathartics, and qui- 
nine. 18th. — Great pain and tenderness of the abdomen 
complained of ; tympanites ; patient lies on her back, with 
her knees drawn up ; her face has an expression of pain ; 
pulse, 164; respiration, 38. Ordered a turpentine stupe to 
the abdomen, and an anodyne, hyoscyamus and camphor. 
Thi'ce hours later she vomited a greenish material. Her 
respiration had increased to forty-four in the minute, and 
wholly thoracic ; pulse 164 ; is not suffering much pain ; 
has passed to-day 54 ounces of urine. 19th. — ^There is no 
improvement in her condition. There is still no suppression 
of the lochia. In the afternoon she was transferred to a med- 
ical ward, where she received a hot-air bath, and was kept 
moderately under the influence of opium, until the morning 
of the 20th, when she died. Mind clear. Autopsy at 3 p.m., 
April 2l5z5. The abdominal cavity contained about six quarts 
of fluid. Slight signs of exudation of lymph on the intes- 
tines. Liver somewhat enlarged, and apparently fatty. Kid- 
neys were fine examples of the large white variety, so pro- 
nounced by Prof. Alonzo Clark. The uterus contained a 



EELATIO^'S OF ALBUMIMTETA TO PREGNANCY. 6 

clot the size of a plum. Heart slightly lijpertrophied, but 
otherwise healthy. Lungs appeared healthy, though the 
lower lobe of the right lung was carnified. Brain normal. 

Prof. A. Flint, Jr., M. D., furnished the following report 
of the microscopic appearance of a portion of the kidneys, 
liver, and heart : — Kidney. " The conyoluted tubes of this 
specimen were completely filled with dark granular matter, 
which did not, however, have the appearance of oil. Parti- 
cles of these granules were also found in the IVIalpighian 
bodies. The granules were markedly cleared up by the ad- 
dition of acetic acid. — Liver. The cells of the liver w^ere dark, 
and filled w^th the same kind of granules which were ob- 
served in the kidneys. There was not an unusual quantity 
of fat, although the nuclei in most of the cells were obscured. 
The granules were cleared up by acetic acid. — Heart. Per- 
fectly normal." 



Case 2. Albuminuria / secretion of urine very marhedly 
diminished in quantity / rigid cervix treated with douche and 
Barnes^ dilator '^ still-'born j^utrid child, with syphilitic 
liver / mild diphtheria and laryngitis subsequent to confine- 
ment / recovery of mother. — Dr. Mead, House Surgeon. 

Annie Hannegan, German; single; primipara; admit- 
ted to the hospital May 14, 186T. Her legs are very oedem- 
atous. She complains neither of headache, nausea, nor 
disturbance of vision. The urine becomes almost solid when 
tested by heat and nitric acid, l^o casts can be found. May 
loth, 6 p. M. She has passed only one or two ounces of urine 
to-day ; and it appears that she has passed but a very small 
quantity for the last three days. The catheter being intro- 
duced, only a drachm of urine is found in the bladder. Com- 
plains of pain over the region of the uterus ; os undilatable ; 
foetal heart inaudible ; breech probably presenting. Dry 
cups over the kidneys, and hot-air bath ordered. Dr. Elliot 
then consulted, ^vho approved the treatment, and ordered, in 



4 OBSTETEIC CLINIC. 

addition, a brisk cathartic and diuretics, and warm donclies, 
for dilatation of tlie cervix ; deeming it desirable that the labor 
should be brought on as soon as possible. Five grains of the 
mild chloride were given, followed by the sulphate of mag- 
nesia. Two doses of this having been vomited, a scruple of 
the compound powder of jalap was given, which moved the 
bowels freely. 11 p. m. A gallon of warm water was in- 
jected against the inner border of the os. May 16^A, 3-1 
A. M. !N"o dilatation. Douche repeated. 8 a. m. l!^o effect ; 
a third douche. The catheter was passed several times dm-- 
ing the night, and one ounce of urine drawn at one attempt, 
and not more than half an ounce at the others. All the spe- 
cimens albuminous. 11.30 a. m. Fourth douche. 1 p. m. 
Os slightly dilated, admits the ends of two fingers. Dr. 
Elhot saw the patient at 2 p. m. with the class, and advised 
the douches to be continued. 3 p. m. Fifth douche. 6.45 
p. M. Sixth ; OS now dilated to the size of a dollar, and still 
rigid. 10.15 p. m. Dr. Elliot saw the patient, and as the os 
was dilating very slowly under the douches, he introduced, 
at 10.45, the smallest-sized Barnes's dilator, and injected sev- 
eral syringesful of warm water, and increased that quantity 
so soon as the cervix would permit. The m*ine has been 
carefully drawn by the catheter dm^ing the whole day, and 
not more than six ounces have been secreted during the last 
twenty-four hours. May 17th, 1.15 a. m. Dilator removed. 
Cervix dilated to 2^ or 2J inches in diameter. At this time 
the membranes were beginning to protrude from the cervix ; 
and as the cervix and presenting part were so high, it was 
hoped that time and the labor-pains would bring them bet- 
ter within reach. The presenting part can be reached with 
difficulty. It is not the head, and is probably the breech ; 
though the exact differential diagnosis between that and the 
shoulder cannot be made. At 4 a. m. Dr. Taylor also saw 
the patient. The os was now contracted and oedematous. 
The largest-sized Barnes's dilator being now introduced, and 
injected with eleven syringesful of warm water, the cervix 



EELATIOXS OF ALBUMINURIA TO PREGI^ANCY. 



was fuUj dilated within a quarter of an hour, when Dr. 
Elliot ruptured the membranes, and recognized the breech 
of a male child. The labor was then allowed to progress. 
Two ounces of albuminous urine drawn by the catheter. 
The m'ine has been carefully and repeatedly examined mi- 
croscopically, but no casts can be found. 11 A. m. The 
breech now appears at the vulva. The body having passed 
without traction, the arms were found extended above the 
head, and were drawn down by Dr. Elliot, in presence of the 
class. In this manipulation, the integument was stripped 
from the putrid body of the child. Previous to delivery of 
the head, attention was called to the great size of the abdo- 
men, which suggested a suspicion of twins ; but when the 
head had been delivered by traction, it was found to be 
greatly enlarged by fluid between the scalp and cranial 
bones ; and this was followed by a gush of a little more than 
a quart of liquor amnii. The placenta came away in ten 
minutes, and was very large, weighing two pounds and 
eleven ounces. It appeared fatty, but was not so recognized 
by the microscope. After delivery, the uterus contracted 
well. Pulse, 90 ; respiration, 44. Extra diet ordered to be 
continued, and the abdomen to be enveloped in oiled silk 
placed beneath the bandage. 3 p. m. Passed a pint of urine. 
6.30 p. M. Pulse, 80 ; respiration, 36 ; skin moist ; no pain 
over uterus or abdomen ; no headache. May V^ih^ 10 a. m. 
Has slept well; pulse, Y6; respiration, 20. 1 p.m. Has 
passed about a pint of albuminous urine since 3 p. m. yes- 
terday. Some inflammation of fauces has appeared. 9 p. m. 
One pint of urine. May Vdth. Pulse, 120 ; respiration, 30. 
Milk appearing. Lochia normal. 6 p. m. Pulse, 130 ; res- 
piration, 38. Tenderness over uterus and abdomen, tym- 
panites. Ordered turpentine stupes, and ten drops of the 
tincture of belladonna every three hours. 3fay '^Oth, 10 a. m. 
Has slept well. Pulse, 100 ; respiration, 32 ; no pain or 
tenderness over abdomen. Urine normal in quantity. 6 p. m. 
Pulse, 108. Eighth of a grain of the sulphate of morphia 



HBi 



6 OBSTETEIC CLIXIC. 

every three hours. Aphonia. Some laryngitis. May 21,s^, 
10 A. M. Pulse, 100 ; respiration, 22. A diphtheritic patch 
on posterior pillar of fances. This was tonchecl with a strong 
solution of tannin in glycerine, and the neck was wrapped 
in flannel soaked in laudanum and hot water, and covered 
with oiled silk. May 23c/. Pulse 80. Throat symptoms 
much relieved. Urine, when drawn by catheter, still albu- 
minous. May ^'^ih. Lochia have ceased. Transferred to 
medical wards. Continued to do well, and discharged at 
the customary time. 

The autopsy of the child showed a large amount of fluid 
between the scalp and cranial bones ; and the presence of 
numerous yellowish points in the liver, with the following 
microscopic appearances, as observed by Prof. A. Plint, Jr., 
M. D. Liver-cells rather smaller than usual, not otherwise 
abnormal. Xo increase in amount of fibrous tissue in that 
organ. Some of the little bodies called cytoblastions, not 
afi'ected by acetic acid, and supposed to be characteristic of 
syphilitic formations. Still, Dr. F. scarcely considered them 
to be sufficiently numerous and distinct to make a diagnosis 
of syphilitic degeneration, from the microscopic appearances 
alone. 

Dr. Southack, the cm-ator, and Dr. Delafield, the assist- 
ant cm'ator, from examination of the specimen and the mi- 
croscopic appearances, were confident that the liver was the 
site of syphilitic deposit. 

Under the microscope, the placenta presented nothing 
abnormal. 

Puerperal Albuminuria and Eclampsia. — The cases of 
Bridget Conway and Annie Hannegan (Nos. 1 and 2) illus- 
trate some of the risks of the puerperal state on which a 
flood of light has been thrown within the last twenty years. 
The greatest advantage gained from our knowledge has been 
in prophylaxis. 

There is nothing more striking in the recent progress of 
pathology, than a comparison of the results for which we 



RELATIONS OF ALBUanN'IIRIA TO PEEGNANCY. 



look in the autopsy of women dying from pnerj3eral eclampsia 
nowadays, and those which were sought for before the coin- 
cidence of puerperal albuminuria and eclampsia had attracted 
attention. Instead of suspecting the brain, we now study 
the kidneys. That we have reached the ultima thule of 
our investigations is not even imagined, but our successors 
must recognize that we have made a great step in advance, 
and that we are working in the right direction. The 
pathology of the blood remains comparatively unexplored, 
and the relations of that fluid, and of the nervous system it- 
self, to the proximate cause of the convulsions, as well as the 
influences of other toxsemic conditions, offer wide fields for 
exploration. 

But meanwhile we enjoy great privileges in the study 
and treatment of these cases; and though the mortality must 
continue large, we have the satisfaction of knowing, and of 
proving, that such a result is unavoidable. 

Frequency of Albuminuria in the Puerperal State. — 
It is a rule in Bellevue that the urine of all pregnant women 
admitted into the waiting wards should be examined ; and 
albumen, at least, is always looked for. 

During the month of Ajpril^ 1867, Dr. Forman examined 
the urine of sixty-eight pregnant women, with the following 
result : Albumen was only found in two specimens, both of 
which were from primiparse. One of these specimens (Case 
1) contained large granular casts, and the patient died soon 
after confinement. The other specimen was taken from a 
woman who left the liospital before her confinement, and 
passed from under observation. Some few small hyaline 
casts were found. 

During Sejptemher, 1867, Dr. W. B. Fisher, house phy- 
sician, examined the urine of fifty-two pregnant women for 
albumen, without finding any. 

Rejport of examination of urine of pregnant women ad- 
mitted to Bellevue Hosj^ital during the month of May ., 1867. 
Dr. Mead, House Burgeon. — Lizzie Cross, albumen and fatty 



» OBSTETEIC CLmiC. 

casts. Discharged before confinement. Ellen McMahon, al- 
bumen, and one waxy cast, found by Dr. Flint, Jr. Safely 
confined. Mary Smith, albumen, no casts. Delivered safely, 
May 28th. Celia O'J^eil, albumen, granular and large hya- 
line casts. Died of puerperal convulsions. Annie Hannegan, 
albumen, no casts. (Case ISTo. 2.) Lizzie Bowns, albumen, 
no casts. Discharged before confinement. Jane Miller, al- 
bumen and granular casts. Delivered July 3d, with no 
trouble whatever; convalesced favorably. Ellen Heeves, 
albumen, no casts. Delivered June 9th. 'No unpleasant 
symptoms during or after confinement. The urine of thirty- 
seven other women was examined chemically, but, as no al- 
bumen was found, further examination was not made. 

Dr. William A. Lockwood, house surgeon in Bellevue, 
reported to me the examination of the urine of fifty-eight 
women in a service extending from April 26th to May 23d, 
1865. The specimens were all examined for albumen with 
heat and nitric acid, as is the rule. They were examined 
microscopically for casts, and for sugar, by Horsely's test, 
and the specific gravity and reaction taken. 

In every instance the result for albumen, casts, and sugar, 
was negative. In one of the women, however, albumen sub- 
sequently appeared in the urine at the time of confinement. 
This patient had two convulsions, and subseqently did well. 
All the other patients had easy labors with but one excep- 
tion, which was tedious. 

The specific gravity of one specimen was 1003 and one 
1028 ; forty-two between 1010 and 1020, the great majority 
verging on 1020 ; fourteen between 1020 and 1025. 

Dr. Everett, house johysician in Bellevue, examined the 
urine of fifty-two pregnant women in the waiting-wards 
during July, 1865, with the following result : Reaction 
neutral in three, alkaline in one ; acid in the rest. Albumen 
observed in fom^ specimens; three primiparse, and one a 
multipara. In these the specific gravity was very satisfac- 
tory. One of these patients presented hyaline and granular 



EELATIOXS OF ALBCMINTEIA TO PEEGNANCY. 9 

casts, and anotlier, granular casts. The nrine of another 
patient without albuminuria presented hyaline and granular 
casts. Sp. gray. 1022. 

During Dr. Coreifs service^ in October, 1866, he ex- 
amined the urine of fifteen waiting-women in Bellevue, of 
whom eight were primiparae. One specimen was slightly 
albuminous from a patient in her second confinement, and 
one from a primipara was albuminous, but when the bladder 
of the same patient was emptied by the catheter, no albumen 
was present. 

Tke Bulletin of the Neio York Academy of Medicine^ 
for October, 1862, contains a report of my remarks on the 
relations of albuminuria to pregnancy, the topic assigned 
to me in the debate on the valuable paper of Professor 
Alonzo Clark. 

The report of the examination of thirty specimens ob- 
tained for me in Bellevue by my house physicians, Drs. 
Nealis and Mola^ is there presented, the examinations being 
respectively made by Professor Clark, Professor A. Flint, 
Jr., and Dr. "W. H. Draper ; ten having been sent to each. 



Total. 


Age. 


Pregnancy. 


Below 20— Five. 


Primiparse — Sixteen . 


Between 20 and 30— Twenty. 


Multiparge—Fourteen. 


« 30 and 40— Five. 




8])ecific 


Gravity. 



Between 1010 and 20— Fifteen. 
" 1020 and 25— Twelve. 
" 1025 and 20— Three. 



Ecaction. 


Albumen. 


Casts. 


Crystals. 


Spores, 


Pus. 


Dr. Clark's 
not stated. 
Acid, 18. 
Alkaline, 1. 
Neutral, 1. 


Four cases, of 
which two 
depended on 
pus and one 
presented a 
trace. 


One epithe- 
lial. 


Oxalate of 
lime — nine. 

Uric acid, four. 

Triple phos- 
phate, two. 


Torulae, three. 
Penicilium glau- 
cum, four. 


Four. 



10 OBSTETEIC CLINIC. 

While Resident Physician of the Asylum^ I carefully 
tested with beat and nitric acid the mine of one hundred 
and twelve pregnant women. The urine was mostly ob- 
tained from out-patients, and in nearly every case passed in 
the asylum, where these patients came for tickets to assure 
them care in their labor. Thus the chances of error were 
reduced to a minimum, and the probabilities of the presence 
of albumen increased by the hour of the day when the urine 
was passed. In only two cases did I find albumen. 

These were primiparse, and living in the asylum. Their 
legs and eyes were somewhat swollen. They were put on 
the use of saline cathartics, and had natural labors. In one 
case the albumen had disappeared before labor; the other 
was not examined a second time. 

These results are recorded in the New York Medical 
Times for July, 1853. 

Hesulis. — It appears, therefore, from these examinations 
of the urine of four hundred and thirty-seven pregnant 
women, that albumen has been found in twenty-three cases. 
In three of these, however, it was distinctly proven that the 
presence of albumen depended on the admixture of pus. 
Deducting these, we have a ratio of one in nearly twenty- 
two cases. 

It is to be remembered, however, that a very large pro- 
portion of these women were primiparse, those especially 
liable to the complication. 

Relations of Albuminuria to Pregnancy. — ^In using 
the word albuminuria in its general signification, and con- 
sidering it both as a symptom, and as an exponent of the 
various morbid conditions in which that symptom may be 
present, its relations to pregnancy may be thus stated : 

Pregnancy presents the great clinical peculiarities of 
being — 

1. A special excitor, in very many cases, of albuminuria 
which had not previously existed. 

2. Of materially developing those morbid conditions in 



EELATIOXS OF ALBUHmilElA TO PEEGNANCT. 11 

many clironic cases, in Tvliicli tLej might possibly have re- 
mained latent for a much longer period ; or in which they 
might have disappeared Trithont such excitation ; thus offer- 
ing an inevitable increase of risk, analogous to those which 
we seek to avoid when albuminuria is uncomplicated with 
this state. 

3. Albuminuria in pregnancy is not only liable to in- 
volve all the dangers associated with its existence in other 
conditions of the system, but, in addition, entails a special 
liability to some, as convulsions, or mania. 

4. It may happen that the unfavorable influences of al- 
buminuria, after remaining latent during pregnancy and la- 
bor, may only make themselves felt when it was hoped that 
the dangers of the puerperal state had passed. 

5. The complications of albuminuria may demand the 
consideration, or prompt performance, of all obstetrical oper- 
ations, both during labor and before labor shall have com- 
menced. 

6. Pregnancy presents the special grave peculiarity of 
exposing two lives to the dangers connected with the occur- 
rence of these phenomena in one subject. 

7. Experience encourages us to hope that the continued 
careful study of this subject will enable us greatly to dimin- 
ish the dangers which we know to be associated with these 
conditions of the kidney. 

It is evident, therefore, that it is of vital importance that 
the urine should be examined microscopically and chemi- 
cally dm'ing pregnancy, and that no precaution should be 
omitted which may guard against error. 

Cystitis, acute and chronic, and leucorrhoea, may cause 
such admixture of pus and blood with the urine, as to furnish 
albumen, though its presence, under these circumstances, 
may not indicate the risk of toxaemia. Hence, in cases of 
doubt, including all those in which the specific gravity is 
good, and there are no microscopic phenomena, the urine 
should be drawn with a clean catheter. 



12 OBSTETRIC CLINIC. 

The tendency of the mine of pregnancy to become rap- 
idly alkaline should be remembered, and the reaction shonld 
always be estimated before heat and nitric acid are used. 

A careful microscopic examination of the urine should 
always be made, it having been preserved for that purpose 
in very clean vessels. All the phenomena that are observed 
in all cases of renal disturbance and disease, may be met 
with in pregnancy, and the difficulties which attend their 
recognition in all other conditions may then be encountered. 

My memoranda present me with illustrations — 

1. Of cases where I have regretted that thorough micro- 
scopic examination had not warned me of the likelihood of 
more advanced disease than was suspected from the mere 
presence of some albumen and the mildness of the attendant 
premonitory symptoms, if, indeed, they existed at all. 

2. Of cases wherein certain microscopic appearances, as 
blood-corpuscles coexisting with pain on pressure over the 
kidney, have furnished important suggestions for treatment. 

3. Of cases in which, no albumen being present, the 
microscope alone has detected the evidences of advanced 
renal disease. 

4. Of cases wherein cursory examination having failed 
to present evidences of renal disease, the autopsy has dis- 
closed conditions which a more thorough study would prob- 
ably have recognized, and brought to bear on the prognosis. 

5. Of cases in which repeated examinations during the 
first eight months of pregnancy having disclosed nothing, al- 
buminm-ia and convulsions subsequently occurred, with seri- 
ous consequences. 

It is, however, very gratifying to remember that the 
urine of pregnancy may present all those varieties and 
numbers of casts which are recognized in every stage of 
Bright's disease, but that, after a fortunate labor, these con- 
ditions may disappear entirely, and the patient remain as 
well as those who have presented similar appearances after 
scarlatina and other acute diseases. 



EELATIOXS OF ALBUMINUEIA TO PEEGNANCY. 13 

Hence the difficulties attending the prognosis are in- 
creased bj these facts, although they enable ns to give a 
warmer coloring to the fiitnre prospects of a patient than 
wonld otherwise be possible. 

They stamp the consideration of the induction of prema- 
tm-e labor in these cases with a strong approval, since the 
most propitious time for these favorable changes is after the 
close of pregnancy. 

They force us to remember that, however favorably one 
of these bad cases may have terminated, an individual pre- 
disposition to serious renal disease has been begotten ; that 
future pregnancies demand redoubled watchfulness, and 
more frequent examinations of the urine. 

Primiparse are more liable to puerperal eclampsia than 
multiparse, but it is probable that the danger is greater for 
multiparse. Some multiparse have suffered from puerperal 
eclampsia before, and others have been threatened therewith, 
and hence the acquired predisposition argues an increased 
risk. ^Moreover, it is my conviction that fatal cases of 
eclampsia in multiparge often occur in patients who were the 
subject of unrecognized albmninuria in a former labor. 

It is probable that multiparse are more liable to apo- 
plectic effusions from their age, and the increased clinical 
probability of fatty degeneration of vessels. 

Prognosis. — ^Patients must not be hastily told that their 
condition is hopeless, whatever the microscopic and chemical 
results of the examination of their urine may be. The con- 
sequent alarm or discouragement is always prejudicial, 
and the result may not justify the prognosis. Such hasty 
opinions belong to the beginnings of knowledge. Just as we 
now know that diseased conditions of the heart and lungs, 
recognized by auscultation, may permit a good expectation 
of life in many cases which the early auscultators would 
have decidedly condemned ; so have we reached that time 
when a greater familiarity with the amount and number of 
diseases of the kidneys, and their compatibility with recovery. 



14: OBSTETRIC CLIXIC. 

or, at least, with, life, slioiild teacli us caution in our prog- 
nosis. Again, we cannot tell in the individual case but that 
the alarming symptoms observed in the m-ine may not be- 
token temporary conditions, or conditions of disease limited 
in extent, or afiecting only one kidney, as were observed in 
the following case : 

Case 3. — Post-raortem CcBsarean section j child found 
dead : interesting condition of kidneys. 

I was called suddenly to an out-patient of the Lying-in- 
Asylum, a primipara, with puerperal convulsions. She had 
died before my arrival, and the physicians had just left. 
The husband consented to allow me to open the abdomen, 
and I made the Cgesarean section in the mesian line fi'om 
below the mnbilicus. The operation presented no special 
observation of interest beyond those which were to have 
been anticipated — child dead, &st cranial position — but the 
kidneys differed greatly from each other. They were equal 
in size, but one appeared quite healthy, and the other the 
subject of advanced Bright's disease. Several gentlemen 
had an opportunity of seeing them, and I gave one to Dr. 
Gouley, and the other to the late Dr. Charles E. Isaacs, and 
their microscopic examinations fully confii-med the opinions 
previously formed. The relation of such a pathological con- 
dition to cases of Bright's disease, where the urine might 
present appearances inconsistent with the duration of the 
patient's life and condition of health, forms an interesting 
subject for reflection, and is one of the considerations which 
complicate the difficulties of our prognosis in the diseases of 
the kidney grouped under the name of Bright's disease. 

I cannot write the name of Dr. Isaacs, without offering 
my tribute to the warmth of his friendship, the unselfishness 
of his character, the purity of his nature, and the guileless- 
ness of his heart. His great attainments, and the brilliancy 
of his original investigations, are the least among his claims 
to the recollection of those who could appreciate the gentle. 



KELATIONS OF ALBUMINTJEIA TO PKEGNANCY. 15 

unaffected simplicity of a life clouded by many trials, and 
who can feel that he loved them. 

Anasarca. — The cases of Bridget Conway and Annie 
Hannegan (ISTos. 1 and 2) show the exemption from eclamp- 
sia fortunately met with under peculiarly predisposing cir- 
cumstances. 

Perhaps the extensive anasarca, and peritoneal effusion, in 
the case of Bridget, played a prominent part in conducing to 
this result. It is thought by some that this dropsical effu- 
sion may relieve the blood of its toxsemic principles, and so 
save the patient. Perhaps the poison, which might have 
struck the nervous centres, expended itself on the perito- 
neum. These patients often display marked tendencies to 
puerperal inflammation. 

In the case of Annie Hannegan, we have the right to 
believe that she was saved by the induction of labor, and the 
subsequent increased secretion of mdne. A clinical fact also 
very marked in the case of Bridget. 

Free Secretion of Urine. — This is one of the phenomena 
for which we look most anxiously in many cases of scanty 
secretion, or of large dropsical effusion. The pumps must 
work, or all is lost. 

In the following cases, the danger from continued sup- 
pression of urine after delivery is illustrated. 

Case 4. — Cardiac disease / oedema of lungs / albu- 
minuria / convulsions / forcejps ; death of mother subse- 
quently from sujpjpression of urine / death of child., and au- 
toj^sy. — Br. Chas. H. Ludlum^ House Surgeon. 

Eliza Hamgin, aged twenty-three, Scotch, unmarried. 
Labor commenced February 19, 1867, at 4 A. m. Ten 
days before, she had complained of diarrhoea, when the physi- 
cal signs of mitral regurgitation and oedema of the lower 
lobes of both lungs were recognized. Legs markedly oedem- 
atous. Urine very markedly albuminous, with numerous 



16 OBSTETEIC CLIXIC. 

hvaline casts. Free catharsis was promoted by tlie com- 
poiincl powder of jalap. Under this treatment she improved. 
The oedema of the Inngs and legs diminished, and she could 
walk and breathe comfortablv. The first stage of labor was 
natural : pains strong, and os nteri dilating freelv, so that at 
12.30 p. :m:., when the membranes rnptm-ed, it was almost 
fnllv dilated. The pains continning effective, at foni' o'clock 
in the afternoon the head had reached the inferior strait. 
From this time nntil seven there was no advance, and as 
convulsions threatened, I went for Dr. Barker. Dming my 
absence she had a convulsion, which lasted ten minutes. Dr. 
Barker being unable to come. Dr. Elliot came without de- 
lay, applied forceps, and delivered at once. The occiput 
occupied a position almost transverse, but was slightly ro- 
tated.by Dr. Elliot's hand, so as to bring it opposite to the 
left acetabulum. The placenta came away in thu*ty min- 
utes, the uterus remaining fii-m and contracted after its ex- 
pulsion. The child was a giid, weighing nine pounds, and 
was living, but, after an hour's persistent efforts at resuscita- 
tion, could only be made to breathe very imperfectly : the 
cry being especially feeble. Color persistently good. It 
died six hours after delivery. The patient rallied promptly 
from the chloroform, had no more convulsions, but died 
comatose on the 22d, fifty-six hom*s after delivery, having 
only passed a few ounces of urine after her confinement. 

There was no autopsy of the mother. 

Autopsy of the Child. — Well fonned. Xo blueness of 
sm'face. Brain and membranes normal. The limgs with 
the heart floated in water. Small islets of atelectasis scat- 
tered through both lungs. Heart. — Foramen ovale, open. 
Valves noi-mal. Aorta. — This vessel gave off" branches to the 
upper extremity, and after giving off" the left subclavian, it 
terminated in the pulmonary artery. At the jimction with 
the pulmonary, its size was a little more than one-eighth of 
an inch in diameter. The pulmonary artery gave (~»ff the right 
and left branches, and then received the aorta half an inch 



EELATIOXS OF ALBUMINUEIA TO PEEGNANCT. 17 

above tlieir emergence. At tliis point it was somewhat con- 
tracted in size — a little more than a quarter of an inch in 
diameter. Prom this point the thoracic aorta was distributed 
normally. 

The blood of the child was examined for nrea by the as- 
sistant apothecary, and nrea detected by Liebig's process. 

Case 5. — Piierjjeral edamjpsia : twins / douche / for- 
cejps / version / siipjpression of urine. 

Ann TVinslow, a primipara, strongly built, aged twenty- 
eight years, entered the Lying-in Asylnm during my service 
as resident physician, in December, 1853. When I lirst saw 
her she had drawn her mattress to the vicinity of the stove, 
and was recliniuo; thereon in an exhausted condition. Her 
face was puffy and oedematous, with general anasarca, and 
she complained greatly of diarrhoea. Her urine was loaded 
with albumen. She was revived with stimulus, and her 
diarrhcEa brought under control. Convulsions were antici- 
pated. 

December 30. — As her strength had now rallied, six 
ounces of blood were taken from the lumbar regions by 
cups. 

December 31. — Sinapisms ordered to lumbar regions. 
Yesjyere. Os commencing to dilate. Slept well. 

Janu(wy 1, 1854, half-past eight o'clock, a. m. — Yery 
severe convulsion, followed, in half an hour, by a second, 
equally severe, with no interval of consciousness ; hands and 
arms livid ; tongue bitten ; four ounces of blood taken from 
nape of the neck and lumbar regions ; consciousness then re- 
turned ; OS very rigid ; pains inefficient. One gallon of warm 
water injected against the uterine orifice, in the presence of 
Drs. Beadle and Metcalfe, physicians to the asylum. Five 
o'clock p. M. — A third convulsion, followed promptly by a 
fourth, with no interval of consciousness, but the convulsions 
less violent, and recovery more prompt. Os unchanged. 
2 



18 OBSTETEIC CLIXIC. 

Half-past eight o'clock p. :si. — Foetal heart scarcely distin- 
guishable. Seven drachms of the tinctnre of ergot given, fol- 
lowed by good pains for thi-ee hours, and then a quiet night. 

January 2, nine o'clock a. m. — Os a little more dilated ; 
foetal heart beating. Three gallons of warm water injected, 
in a full stream, with BKgginson's barrel syringe, followed 
by rapid dilatation of the os. Two o'clock p. m. — In the 
presence of Mr. Hunter Adam, an Edinburgh surgeon, I de- 
livered her, without difficulty, of a still-born child, with for- 
ceps ; and, finding the left arm of a second child at the pelvic 
brim, withdrew it, living, by the operation of version. 'No 
trouble with placenta. 

The patient was now kept warm, and gentle saline ca- 
thartics, with diaphoretics, administered. She had a good 
" getting up," and ten days afterwai^d was sitting by the 
stove, bright and happy. 

■ On the following day she had a slight convulsion, and 
never ao-ain reo-ained consciousness. She lived for two or 
three days, with scarcely any secretion -of urine. Gin, beef 
tea, and Hoffman's anodyne, with strong counter-irritation, 
were freely used, but with no effect. 

The post-mortem displayed an advanced stage of Bright's 
disease of the kidneys (white). 

The autopsy was witnessed by Drs. Isaacs and Gouley. 

Jaetitatimi / Restlessness. — These patients often display 
marked and peculiar restlessness; often great jactitation; 
and they are specially prone to suffer from those influences 
which we sum up in the emphatic word " shock." These 
facts are well shown in the following remarkable case. 

Case 6. — Albmninuria ; uterine fibrous tumors ; early 
rupture of. meiiibranes j rigid os j douche j chloroforin ^ 
incision of cervix / f weeps. 

Mrs. , a primipara, aged 26 ; well built ; very 

cheerful ; and believed by herself and her friends to be in 



EELATIOXS OF ALBUMIXUEIA TO PKEGNANCY. 19 

good liealtli ; came under hit care on the 20tli of ITovember, 
1S57. ;^Ienstriiated for the last time February 28th. I recog- 
nized at once tlie evidences of albuminuria. Extremely 
puffy face ; hands, arms, and feet appeared swollen, though 
they would not pit on pressure; constant headache; eye- 
sight distm-bed by flashes of light ; muscse volitantes, and 
blurred outlines ; bowels confined ; thought that the quan- 
tity of urine had diminished somewhat of late. Some of the 
urine passed on the following morning became almost solid 
by the application of heat and nitric acid. Microscopical 
examination neglected. Ordered to take Tarrant's Seltzer 
Aperient, to be cupped over the kidneys, and to send some 
urine for examination on the 2Tth. At this time I requested 
the husband to call at my office, where I tested some of his 
wife's urine in his presence, compared the results with some 
healthy urine, and mentioned my apprehensions of puerperal 
convulsions. 

On the 29th, received two specimens of urine, the one 
passed on the morning of the 28th, after a quiet night, the 
other on the 29th, after a very restless night, in which, to 
use the husband's words, " there was an apparently uncon- 
trollable emission of water mixed with blood." This, which 
was, without doubt, liquor amnii, had probably become 
mixed with the specimen of the 29th, as it evidently con- 
tained blood. The specimen of the 28th contained less 
albumen than the one previously tested. 

On visiting her, found that the headache and amaurotic 
symptoms were persistent, and that so much effect had not 
been produced on the bowels as was desirable. She was 
very cheerful, had no pain, face decidedly less swollen : left 
after desiring that she might have a cathartic, and that the 
nurse should be sent for, as I anticipated labor. 

Labor. — At 3 a. m. of the 30th, was summoned, as the 
nurse thought that the child would soon be born. Found 
her with extremely powerful uterine contractions, which, 
then and later on, w^ould last thirty, thirty-five, and forty 



20 OBSTETRIC CLINIC. 

seconds by tlie watch; liquor amnii dribbling away con- 
stantly; patient excited, very restless, and bearing down 
with her pains ; os nteri very little dilated, rigid, and less 
dilatable than any which I can call to mind ; head present- 
ing, but position not then determined; foetal heart, how- 
ever, decidedly to the right side below the nmbilicns, and 
concluded that the position was the 2d of I^aegele ; which 
was subsequently ascertained to be the fact. Pelvis well 
formed. 

On examining the abdomen, found a hard tumor at about 
the junction of the left iliac and umbilical regions. It 
seemed about the length of the forefinger, with a firm pedi- 
cle. This, on examination, I decided to be a fibrous uterine 
outgrowth, and mentioned to the husband and others the 
likelihood of another on the posterior wall, as these are very 
rarely single. 

The uterine contractions continued as vigorous as ever, 
slowly forcing the head and cervix toward the pelvic cavity, 
but without any effect on the os ; so I used the warm-water 
douche, and repeated the same three times during the day, 
but with no effect. 

Told the patient that I would give her chloroform, but 
would not promise that its influence should be kept up until 
the labor had terminated. In the afternoon she consented 
to take it for two or three hours, during which time she 
slept peacefully, with no abatement of the uterine contrac- 
tions. 

At about half-past seven in the evening, the pulse, which 
had been rather slow, was becoming somewhat excited; 
bodily and mental restlessness extreme ; uterus long since 
drained of its waters, with the os as undilatable as it had 
been for twenty hours, down in the cavity of the pelvis, and 
slightly lacerated on the left side ; foetal heart beating ; peri- 
neum rigid. 

I then told the husband that this had gone far enough ; 
that fortunately, and probably from prophylactic treatment. 



EELATIOXS OF ALBrMINUElA TO PREGNANCY. 21 

conTTilsions had not occm-red, but tliat tlie albuminuria still 
overshadowed her ; that the rigidity of the os was such as 
clearly, in my judgment, to indicate the propriety for its 
division (this was ten j^ears ago, when we had not the dila- 
toi-s); that, considering the position of the head, it would 
probably be better to terminate the labor with forceps, and 
suggested a consultation. Professor Barker then became 
associated with me in the management of the case, and saw 
the patient at about half-past nine, when she was well under 
the influence of chloroform. He recognized every point 
which had been made, and warmly approved the measures 
proposed. 

Dr. Schermerhorn having kindly given his assistance 
also, I divided the cervix with Simpson's uterotome on the 
right side, oj)posite the shght laceration referred to. Dr. 
Barker agreed with me in thinking that the forceps might be 
introduced through this opening, which was about the same 
as in a case of incised os recorded by Dr. I. E. Taylor in the 
N. Y. Medical Times. 

The elevation of the head demanded the use of long 
forceps, and the head, promptly grasped, did not slip during 
delivery. After an ineffectual attempt to rotate the occiput 
anteriorly, I delivered a living female child in obedience to 
the rules for this presentation, and with the usual difficulty. 
Unfortunately, the patient being drawn upon the bed, unex- 
pectedly to myself just at the moment when I was about to 
disengage the face, a laceration of the perineum occurred, 
which involved a few of the lower fibres of the sphincter. 

Traces of the forceps on the head of the child were very 
slight, and after plunging the child in hot and cold water 
alternately with frictions, slapping, and occasional resort to 
the "ready method," it cried loudly, and looked well, 
though thin and puny. 

The child presented some paralysis of the portio dura of 
the left side from pressure of the forceps, which, however, 
wore away. As Chailly says : " Tout le monde salt que eel a 



22 OBSTETEic CLnac. 

n'a aucime importance, que qiielques joiirs snffisent pour 
faire disparaitre cet accident." A wet-nnrse was prociu'ed, 
but the babj pined and dwindled awaj, dying wben but a 
few days old. 

After delivery the diagnosis of the uterine tmnor was 
shown to be correct, while another and a larger one was 
found springing from the posterior wall, and met with by 
the right sacro-iliac synchondrosis. About an horn- after 
delivery, the uterus contracting and then lazily relaxing 
over the placenta, entirely retained within its cavity, I re- 
quested Dr. Barker to ascertain if there was any cause for 
delay. He found it attached to the anterior wall, near the 
fundus, and partly adherent, necessitating careful detach- 
ment. He removed it wholly, membranes and all, while I 
maintained tonic uterine contraction, with my hand over 
the fundus. 

Drs. Barker and Schermerhom now left me, as the 
mother and child were doing well, and I remained by the 
bedside for some time longer with my hand over the fundus, 
to guard against the possibihty of uterine hemorrhage. 

Alarming Sym])tom8. — At last, when about to apply the 
binder, there came a sudden and alarming change in her 
expression, pulse, temperature, and respiration. The last 
was slow, jerking, and abdominal, deciding me not to apply 
the binder, lest it should interfere with the action of the 
diaphragm ; the pulse was alarmingly feeble and slow ; the 
face and extremities very cool; and the general expression 
awakened grave anxiety in my mind. The uterus remained 
contracted, and no hemorrhage occm'red. 

Consultation. — Having plenty of assistants, made one 
hold up both legs, and two others the arms ; the head was 
placed on a level with the trunk ; ordered brandy and water 
with strong frictions, while I kept my hand firmly over the 
fundus to insure against the possibility of hemorrhage. IsIy 
assistants could not give the brandy without provoking 
paroxysms of coughing, and so sent my carriage instantly 



RELATIONS OF ALBUMmUEIA TO PREGNANCY. 23 

for Dr. Barker, and, as lie was not at liome, my friend. Dr. 
George A. Peters, was brought to the bedside without a 
moment's delay. He fed her snccessfuUy with brandy, and 
she rallied. After these dangerons symptoms had passed, 
we talked to her of her child, and implored her to calm her 
restlessness, and keep quiet, but with httle avail, for she 
would flounce from one side to the other, throwing her 
pelvis clear from the bed. 

Dr. Peters stayed with me till 3 A. m., giving her brandy 
and milk-punch, and she continued to improve. Her pulse 
was good, her intelligence perfect, but her skin was cool and 
her restlessness very great. 

At this time we thought that -^ve drops of Magendie's 
Solution might calm her excitement, and it was given, when 
Dr. Peters ^^ithdrew. Remained with her till nearly 8 a. m., 
December 1st, during which time she had some refreshing 
naps, though I could not say that the morphine had pro- 
duced any perceptible effect. The uterus remained well 
contracted, and no hemorrhage had occurred: gave her 
seven drops more, and left her, after strongly enjoining the 
necessity for quiet. 

Icelapse. — By ten o'clock I saw her again just after a 
sudden change had occurred similar to that of the previous 
night. She was perfectly intelligent, very much excited, 
lying on her left side, and imploring me to allow her to 
change her position. Scarcely had I promised to lift her on 
her back, when she threw herself completely on her right 
side, raising herself on her heels and shoulders, and her 
heart never seemed to recover its force from that moment. 
She died immediately after having vomited some brandy 
during the prolongation of the agony. With her last words 
she complained that some brandy seemed to have gone the 
wrong way. 'No hemorrhage had taken place. The uterus 
was strongly contracted. 

Post-mortem. — In view of the conditions observed at the 
autopsy, the temperature is important. According to the 



24 OBSTETEIC CLmiC. 

register of Mr. E. Meriam the thermonieter raarked on De- 
cember 1st, at one p. m., 50° ; two p. m., 52° ;. three, 50° ; 
four, 48°; five, 45°; six, 45°; seven, 42°; eight, 40°; nine, 
40° ; ten, 39°. 'No observation from eleven p. m., December 
1st, till S^ve A. M., December 2d. Six a. m., 32° (white frost) ; 
seven, 32°; eight, 34°; nine, 36°; ten, 40°; eleven, 42°; 
twelve, 42°. 

The examination was made by Dr. Geo. A. Peters and 
Prof. W. H. Yan Buren, tw^enty-seven honrs after Mrs. 

's death. The body had remained on the back in a 

room without fire, and with the windows open. 

So great a change had taken place in this time as to 
render the body almost unrecognizable. The face was 
greatly swollen by emphysema, and the surface of the body 
down to mid-leg and to the wrists crepitated in the most 
marked manner. 'No post-mortem discoloration of the abdo- 
men, but post-mortem lividity over the back, and greenness 
of decomposition vtdth bullae over the lateral aspects of the 
trunk, especially over the thorax. On opening the abdomen 
there was so great an escape of gases, evolving a strong odor 
of sulphuretted hydrogen, that we were obliged to open doors 
and windows. Interior of body yet warm. 

Head not examined, by request. Larynx and trachea 
normal. IN'othing of interest in the lungs. Both jpleurm 
universally adherent. Hearty normal in size, contained no 
air in its cavities ; no clot in the pulmonary artery (such as 
terminated the life of the Duchess de ISTemours) ; apparently 
fatty, with patches of atheroma along the aorta. Pericar- 
dium normal. Blood coagulated. 

Microscopic ex_amination of the heart by Prof. Alonzo 
Clark and Dr. C. E. Isaacs. Studded with patches of athe- 
roma externally and along the aorta. ^Numerous whitish 
spots on surface and in muscular tissue, which Dr. Clark 
supposed to be purulent deposits at first; but, on examina- 
tion, no pus was found, but granular matter with globules 
of oiJ. Muscular structure had not undergone fatty degen- 



EELATIONS OF ALBUMIXUEIA TO PEEGNANCY. 25 

eration, but very soft, the least toncli of tlie scalpel producing 
a whole microscopic field of fragments. 

Abdomen. — IN'o peritonitis, or undue amount of fluid in 
the peritoneal cavity; sub-peritoneal cellular tissue every- 
where emphysematous, dissecting off large blebs of perito- 
neum. On greater cm^vature of stomach, cellular tissue 
around gastro-epiploic vessels, so aerated as to simulate 
distension of the vessels. The intestines moderately distend- 
ed with flatus, crepitated everywhere from emphysema of 
their sub-peritoneal cellular tissue. 

Liver, — Crepitated everywhere to the touch, cafe au lait 
in color, and so friable as readily to break down in the ne- 
cessary manipulations for removal. Fatty under the micro- 
scope. 

Sjpleen. — ^Apparently normal, except similar crepitation. 

Kidneys. — Excessively soft, crepitating to the touch; 
their capsules dissected by the emphysema. ITo marked 
appearance in one not found in the other. 

The late Dr. C. E. Isaacs furnished me with the follow- 
ing memoranda of their condition : 

" In the hottest weather of summer I have often made 
post-mortem examinations of subjects which had been dead 
nine or ten days, and wherein the organs were not as much 
advanced in putrefaction as in the present instance. The 
liver, kidneys, and uterus crepitated strongly under pressure, 
from the presence of gases among their tissues. The cap- 
sule of the kidney was perfectly loose, and separated with 
the slightest tou-ch. On separating it, the cortical surface 
exhibited numerous elevations and depressions, as in the 
cirrhosed kidney. The cortical substance was very much 
softened, and easily broken down on slight pressure, and 
gave the same sensation as the lung when this is cut into 
by the scalpeh On microscopical examination, the kidneys 
were found in an advanced stage of Bright's disease. Tlie 
Malpighian bodies were of various sizes, some of them very 
small. The fibrous ring of the matrix surrounding them was 



26 OBSTETEIC CLDsIC. 

mucli tliickened. Tlie capillaries of tlie Malpigliian tnft con- 
tained nnmerons oil globules, as did also tlie minute arteries 
of tlie cortical substance. The tubes were generally, and in 
many instances entii'ely, denuded of their epitlielial cells ; 
many of Tvbicli were disintegrated, or resolved into granular 
matter. In the numerous specimens wliicli I examined, I 
could not find any tiling like bealtliy structure in tlie cortical 
portion. It is an interesting question liow far the diseased 
state of the kidney, and the consequent retention of the ele- 
ments of the urine in the blood, contributed to the rapid de- 
composition of the different organs." 

Dr. Clark coiToborated the statement of Dr. Isaacs, and 
added that many of the cells in his specimen were loaded 
with fat. Dr. Clark had also made the independent sugges- 
tion that the excessively rare degree of softening observed 
was probably due to some ante-morteln septic influence with 
which we are not familiar. 

Uterus. — Firmly contracted, and emphysematous. Ee- 
moved for examination, together with heart, kidneys, and 
portion of liver, when they were also submitted to Professor 
A. Clark and Dr. C. E. Isaacs, and shown to the Pathologi- 
cal Society. 

The uterus displayed two sub-peritoneal uterine out- 
growths, fibrous in character, irregularly shaped, and pedi- 
culated ; the smaller one, situated on the anterior surface, to 
the left of the mesian line, about midway between fundus 
and cervix. The other, posteriorly, to the right of the 
mesian line, near the junction of the body and cervix. The 
former measm-ed two inches in length, and three-quarters of 
an inch in width ; the latter foiu* inches by two and a quarter. 
The fundus anteriorly presented a smaller fibrous tumor, the 
size of a split white bean. 

On examining the os uteri from within the vagina, no 
appearances of sphacelus, nor of laceration extending to peri- 
toneal coat, were observable. Traces of the incision were 
distinguishable, as well as some other slight solutions of con- 



RELATIONS OF ALBUMINURIA TO PEEGNANCY. 27 

tiniiitT, but none of tliem differing from wliat maj frequently 
be observed after parturition. On section of the anterior 
wall tlirongh tlie mesian line, tlie nterns was found firmly 
contracted, tlie cavity contained a clot which was estimated 
to weio^h less than an ounce. 

On careful examination, the internal surface presented no 
appearance whatever of injury. 

Microscopical Examination ty Drs. Clarh and Isaacs. — 
Fibres of inner surface certainly undergoing fatty degenera- 
tion. ]^o evidence of any inflammatory condition. 

Case 7. — Albuminuria / miscarriage / jactitation. 

In another case I witnessed this jactitation to a painful 
extent. A young primipara applied to me to take charge 
of her in the approaching confinement. She was then nearly 
three months gone, and perfectly healthy in appearance. 
She miscarried, however, soon after, and was taken care of 
by another physician, and some days subsequently I was 
sent for in consultation. She presented the most painful 
restlessness, with rapid and feeble pulse, and suffered from 
intense coldness of the legs and arms. The phenomena were 
not unlike those of hysteria, but the urine was found to be 
loaded with albumen, with waxy casts, and she continued to 
sink, and finally died without eclam]3sia, retaining her con- 
sciousness till near the end of her life. 

In the following case the restlessness and excitability often 
observed in these patients was singularly well marked. 

Case 8. — Fuerjperal eclamjpsia ; albuminuria j efforts 
atmanual dilatation of cervix J douche,' Barneses dilators ^ 
stiUr-lorn putrid child delivered hy manual traction j mar'ked 

restlessness. 

On the 29th of July, 1864, Dr. John C. Hutchison sent 
for me to see Mrs. , of Brooklyn, aged thirty-six. She 



28 OBSTETRIC CLIXIC. 

liacl tlirice miscarried at the second or third month, and was 
now near the eighth month of gestation. She was very stout, 
weighing about two hundred and fifty pounds; a hearty, 
healthy-looking woman of a very nervous temperament. 
'With the exception of the miscarriages referred to, she had 
always been a healthy woman ; but about two months ago 
she presented evidences of oedema of the face and upper ex- 
tremities, which led the doctor to make several examinations 
with heat and nitric acid for albumen, but none could be 
found. 'No microscopic examination made. Secretion nor- 
mal in quantity. She was kept under the use of saline 
cathartics, and not allowed to use any meat. Six leeches 
were applied over the kidneys. Warm hip-baths. During 
the night of the 26th and 27th the patient was extremely 
restless. Dr. Hutchison saw her at seven p. m., 26th ; she 
had just returned from a long ride, and was considerably 
fatigued. Complained of pain in nucha ; headache did not 
occur until about three hom^s subsequently. At four a. ii. of 
the 2Tth she fell into a well-marked epileptiform puei-peral 
convulsion, dm'ing which she bit her tongue. Consciousness 
returned ; vs. ad I xx. and a mercurial cathartic, althougli 
there had been some diarrhoea lately. At five a. m. another 
convulsion, and between that hour and nine p. m. she had 
thirteen convulsions in all. Her consciousness would re- 
turn in the intervals, though she was not entirely rational. 
Very nervous and excited. Jactitation most marked and in- 
cessant. It was endeavored to anticipate the convulsions by 
the use of chloroform, and Dr. McClellan was brought in 
consultation. After his arrival an effort was made to dilate 
the cervix uteri manually. The cer^-ix was high up, long, 
and entirely undilated. "With care and time the ends of 
three fingers were introduced, but it was not further dilata- 
ble. During the night of the 2Tth she was kept for the most 
of the time under the influence of chloroform. On the 
morning of the 2Sth several convulsions were arrested by 
chloroform. Bowels freely opened. Urine abundant and 



KELATIOXS OF ALBUMIXUEIA TO PREGNAls^CY. 29 

sometimes diseliarged unconsciously. 'No furtlier dilatation 
of the cervix, and not a labor pain. Occasionally conscious. 
Douche of warm water within the cervix once for twenty 
minutes. Complained of epigastric pain and vomiting, 
which were relieved by a di^achm of the bicarbonate of 
soda. Great jactitation. Complains now, and has before, 
of a "blm-" over the eyes. 29th. Extremely nervous, much 
jactitation, but not to so great an extent, as the patient is 
weaker. No convulsions, as their approach is anticipated 
by chloroform, of which she requires very little and which 
seems to agree with her admirably well. At two p. m. com- 
plains, for the fii'st time, of pain in her back and lower part 
of her bowels, which recurred in half an hour. Four p. m., 
cervix lower, soft, and dilatable. Head presents. Such was 
the history of the case given to me on my arrival by the 
doctor, who had been almost constantly by the bedside for 
about thirty-eight hours. 

I found the patient in a perfect twitter of excitement, 
talking, screaming, twitching convulsively, very restless, ask- 
ing hurried questions, very fearful of being hurt or touched, 
and apprehensive of evil. Conscious of all that was going 
on, but intelligence still clouded. Skin of good temperature ; 
strength good ; pulse 160, full and strong ; lips of good color, 
but the pupil of the eye much contracted, although there 
was not much light in the room, and her face turned away 
from what there was; the eyes were glassy. There was 
some oedema of the legs. Yagina of good temperature and 
free from offensive discharges. Cervix uteri dilated to about 
the size of a dollar, well enough down, and entirely undilata- 
ble to the fingers. Membranes ruptured, but exactly w^here 
could not be determined. Head recognized to present, and 
some of the puckered scalp had passed through the cervix. 
Cranial bones did not move on each other when touched. 
No foetal heart or foetal movement to be recognized or pro- 
voked. (Labor-pains at two p. m. 29th, commencing in back ; 
recurred every half hour until about 9 p. m.) 



30 OBSTETEIC CLIXIC. 

It vas evident tliat prompt delivery was most essential, 
and yet thorongli manual dilatation and the doncbe of the 
previous day had not advanced matters as satisfactorily as 
could be wished. I recommended the use of Barnes's dila- 
tors, which I had brought with me, and the prompt delivery 
of the foetus as soon as dilatation could be effected, and 1 
left. It was then nine p. m. Dr. Hutchison then intro- 
duced the medium-sized dilator which I left with him, and 
having distended it as far as the cervix would allow, left it 
in situ. It remained an hour, when it was found in the va- 
gina, and the cervix appreciably dilated. He reintroduced 
it twice, and the thii'd time he dilated it to its fullest extent, 
and withdrew it at one a. m. of the 30th with some little dif- 
ficulty, as the cervix, although sufficiently dilated to admit 
the hand, still yielded sluggishly and preserved its undilatable 
character. The doctor now introduced his hand and carried 
it carefully up to the neighborhood of the child's feet with 
the intention of tm-ning, but at the same time the patient 
seemed to grow rapidly weak, abdomen became suddenly 
tympanitic at half-past twelve a. m., -attended with vomiting 
of a dark-green fluid. Xo sharp pain, and the uterine con- 
tractions, which had been of scarcely any force, ceased for a 
time, although they subsequently returned. Giving up the 
idea of version, the doctor now examined the head carefully, 
and found that the bones could be moved on each other ; 
and grasping the puckered scalp and the angle of a parietal 
bone, he withdrew a male child, aided by feeble uterine con- 
tractions. Placenta came away in a few minutes ; no post- 
partum hiemorrhage ; uterus contracted well. The mother 
continued to sink, and died at three a. m. of the 31st. I was 
sent for when she was sinkino- and arrived after her death. 
The child weighed about -Qxe pounds. Its cuticle was dis- 
colored, and peeled off readily. ISo autopsy. 

Physiognomy in Albuminuria. — Bridget Conway's face 
(Case 1) was very pale and bloodless, and no sign of oedema 
showed itself there until after the labor had occurred, when 



EELATIONS OF ALBTJMINIIRIA TO PEEGl^AITCY. 31 

it Tras probably due to tlie recumbent position. The limbs, 
however, were greatly swollen. 

"We have no right to rely on the physiognomy of the pa- 
tient in this disease. "We may, indeed, strongly snspect that 
a pale, puffy-faced j)i'egnant woman, with swollen fingers, 
and moderate general anasarca, is the subject of albuminuria ; 
but we may be mistaken, and the phenomena may occur in 
the patient who presents no outward appearances of the 
affection. It follows, therefore, that we must rely on ex- 
amination of the urine alone. I have been struck, however, 
on more than one occasion by the marked clinical differences 
in the photographs of patients taken before and after the de- 
velopment of Bright's disease. 

Case 9. — Albuminuria and BrigMs Disease. 

A patient of mine, whom I had taken care of in both 
coniinements, which were natural, was slenderly bnilt, with 
delicate features, and a gentle, engaging expression. Some 
months after the birth of her second child, I w^as consulted 
for some symptoms which occasioned anxiety in the family ; 
and I found, after a while, that she was addicted secretly to 
drinking. This she told me was rendered necessary to her 
by a peculiar feeling of distress which she could not explain. 
It is my belief that the habit was nltimately discontinued, 
but a very marked change took place in her physiognomy, 
rendered most striking by the expression of photographs 
taken at different times. She became drowsy, and her urine 
exhibited a large amount of albumen, and vast numbers of 
casts. A specimen of her urine, while yet warm, was ex- 
amined by Dr. J. W. S. Gouley, who found casts of different 
sizes and all varieties throughout the fluid, without having 
to wait for any deposit. Under these circumstances I gave 
a very grave prognosis. This led to their taking other ad- 
vice until they found a practitioner who did not share my 
apprehensions, and promised a cure. Their hope was still 



32 OBSTETEIC CLIA^IC. 

further awakened by a temporary rally in her forces, but she 
soon succumbed to her disease. 

Case 10. — Albimiinuria y eclampsia / forceps. 

Dr. "Winter sent for me on the 14th of September, 1861, 
to a primipara, aged twenty, in puerperal convulsions, which 
had then recurred during five hours. She was unconscious 
on my arrival, and had been so for two hours. Head pre- 
senting in the first position, descent completed. Dr. W. 
kept up the moderate use of chloroform, and I delivered a 
living child with forceps. This young mother, like so many 
others, presented, on careful examination, neither puffiness, 
pallor, nor oedema, nor any expression of the albumen with 
which her urine was loaded. Mother and child did well. 



CHAPTER II. 



PKOPHTLAXIS OF PUEEPEEAL ECLA]MPSIA. VAEIETIES OF PUEE- 

PEEAJL CONYULSIONS. 

Prophylaxis of puerperal eclampsia. — Case: Puerperal eclampsia; profuse 
salivation from a mercurial purge. — Purgatives ; diaphoretics ; acids ; diet. 
— Case: Albuminuria; puerperal eclampsia. — Induction of labor as a 
prophylaxis. — Case: Puerperal eclampsia; induction of labor; Barnes's 
dilators; forceps. — Case: Albuminuria in pregnancy. — Case: Puerperal 
eclampsia; induction of labor. — Case: Albuminuria and eclampsia in the 
first confinement ; albuminuria and induction of labor in the second by the 
douche. — Ca^e: Puerperal eclampsia ; induction of labor ; Barnes's dilators ; 
douche; forceps. — Varieties of puerperal convulsions. — Case: Puerperal 
convulsions ; no renal disease ; consciousness not abolished ; douche,— 
Case : Hysterical convulsions and hemiplegia. — Case : Poisonous effects of 
an infusion of stramonium-leaves injected in the rectum. 

Projohylaxis ofPiterperal Eclampsia. — Eliminate through 
the bowels, the skin, and perhaps the kidneys. Consider the 
advisability of inducing labor; and of abstracting blood. 
Diminish the supply of meat and nndigestible food. Re- 
move exciting and depressing influences. Do not debili- 
tate the patient. Ward off threatening attacks with chloro- 
form or sedatives. 

Women are generally constipated, but the habits of the 
patient and the present condition of the bowels should 
be inquired into before the purgative is selected. Mer- 
curials may produce unfortunate results occasionally, as in 
the following case taken from my note-book, and observed in 
the Dublin Lying-in Hospital during my residence there as 
pupil in 1849. 
3 



31 0B3TETEIC CLINIC. 

Case 11. — Puerj^eral edamjma j jjvofiise salivation from 
a mercurial jpurge. 

, 8et. 33, robust, sliort-necked, and very pletli- 

oric, was taken in labor with ber seventh child, under the 
care of a midwife. Her former laboi'^ had been natural. 
This time the breech presented, and she was attacked with 
convulsions, for which she was sent into the hospital, where 
she arrived in a comatose state. Her feet and legs were 
much swollen, and her urine albuminous. She was largely 
bled, and had a tm'pentine injection. The labor terminated 
promptly, and to the best of my recollection without assist- 
ance. The child was dead. She lived for some days, many 
times convulsed and stupified, and almost motionless in the 
intervals ; yet, when loudly questioned and shaken, she 
would answer, always replying that she was better. So 
sensitive was she to the action of mercm*}^, that ten grains of 
calomel salivated her profusely, loosening her teeth, and 
causing several to fall out, and she more than once pointed 
to her mouth in a vague and complaining way. The day 
before her death she recognized her husband. The autopsy 
showed no lesion of the brain, but the kidneys were pro- 
nounced to be well-marked examples of Bright's disease in 
an advanced stage. 

This, however, is the only case of salivation which I have 
met with in these conditions, and it may bave been, and 
indeed it probably was, solely a coincidence. On the other 
hand, the mild chloride is a medicine very easily given, and 
renders the subsequent action of other medicine more prompt 
and certain. Mixed with butter, and placed on the back of 
the tongue, it and otlier pow^ders are readily swallowed by 
the comatose patient. 

Purgatives^ Bia/phoretios, Diuretics, Diet. — The prophy- 
lactic virtues of mercurials, in minute alterative doses, are 
very efficient in certain cases. The corrosive chloride de- 
serves to lead the list, and may be combined with advantage 
with bark, and even with iron in some cases where the hydi'se- 



PEOPHTLAXIS OF PUEEPEEAL ECLAMPSIA. 35 

mia is very marked, the head symptoms absent, and the 
experiment well borne. 

The best cathartics for the prophylactic treatment, in my 
opinion, are preeminently the salines, steadily and intelli- 
gently used. The Saratoga waters ; magnesia, and Rochelle 
salts, preceded by colchicnm, where there is great acidity 
and a rheumatic or gouty diathesis. Epsom salts and jalap, 
or the compound powder of jalap, in most cases, are efficient 
and reliable. The acidulated bitartrate of potassa is very 
grateful. If there be delay, enemata are yaluable ; and they 
should generally be used in the case of a patient seen for the 
first time, and threatened with eclampsia. Francke's dinner- 
pill {grain de sante)^ made from aloes and the extract of 
jalap, has long been my favorite medicine of its class. The 
combination is good, and the ingredients excellent. In some 
cases of hopeless Bright's disease I have known great tem- 
porary benefit to follow the administration of elaterium and 
the apocyanum cannabinum. In the cases we are consider- 
ing, these powerful remedies and croton oil may possibly be 
required, but it is better to avoid them if possible. 

The skin should always be stimulated to increased activ- 
ity. More than one author has truly said that no man 
ought to expect health who has not been thrown into a good 
perspiration at least once a day. All Americans who in- 
habit a dry climate have need to bear this specially in mind. 
For many years in Bellevue, when diaphoresis is desired, 
patients have been packed in blankets, and hot air intro- 
duced within these by a portable apparatus. As a rule, 
very free perspiration can be promptly induced in this way. 
Bags of potatoes or corn steaming hot ; heated bricks in wet 
cloths ; lime placed in pans, or sections of tubes, and then 
slaked (care being taken thai; the patient shall not be 
burned), are efficient remedies, always available. Ronchetti's 
portable hot-air bath is excellent, and the best of its class. I 
find it very useful in these cases, and in the treatment of 
rheumatism and other diseases in which diaphoresis is indi- 



6b OBSTETRIC CLINIC. 

cated. I send my patients (not pregnant) with chronic 
albuminuria, as well as those with gout and rheumatism, 
certain dyspeptics, those with psoriasis, and others, to the 
Turkish and Russian baths, with the conviction that I am 
meeting a desirable indication. It would probably benefit 
many pregnant women also. Some of these days, the pro- 
phylactic use of these baths will be proven, their uses more 
widely appreciated, and they will become a national need. 

I have never hesitated to try diuretics in cases of albumi- 
nuria in connection with the methods indicated above, 
selecting such as are the least stimulating, and act more by 
their bulk and weight — if the expression may be permitted. 
A free use of water, sweetened, or acidulated with lemon- 
juice, or fruit-syrups ; carbonic-acid water ; Yichy and Selt- 
zer waters; and such tisanes as tempt the palate, while they 
meet the indications, command my preference. I have used 
the bromide of potassium for this purpose, and for quieting 
the excitability and sleeplessness of some patients. "Where 
there is tenderness over the kidneys, or blood-corpuscles in 
the urine, or where the symptoms are acute, dry or wet 
cupping, or counter-irritation over the lumbar regions, must 
be considered, is generally beneficial, and may increase the 
secretion. 

I do not feel prepared to give an opinion regarding the 
efficacy of benzoic acid, lemon-juice and tartaric acid, in 
these cases of blood-poisoning. It is better that they should 
be given, however, especially the latter, as they will not do 
harm, and are claimed on high authority to be efficient. I 
have long been in the habit of using the mineral acids in 
cases of albuminuria in bilious subjects, and especially where 
the oxalate of lime is present. In some cases of headache 
the phosphoric acid is very beneficial, especially in delicate, 
pale, impressionable patients. 

I prefer to deprive these puerperal patients of the use of 
meat, or rather to regulate its use, unless it should be obvi- 
ously necessary in a special case. 



PEOPHTLAXIS OF PUEEPEKAL ECLAMPSIA. 37 

Under tliis line of treatment, varied according to the pa- 
tient's strength and tone, many cases of albuminnria in the 
puerperal state have been relieved, and the dark clond lifted 
fi'om the coming labor. Bnt the improvement mnst be per- 
manent, not temporary. The predisposition is there, and 
mnst be kept in abeyance. 

This very fact teaches us additional caution. Time is an 
element in the prognosis. 

Case 12. — Albuminuria j convulsions ; death in next 
pregnancy. 

Mrs. , a patient of the late Dr. Bolton, forty-odd years 

of age, seven months gone in her fonrteenth pregnancy, has 
had no trouble in any former confinement. She now suffers 
{January^ 185S) with amaurotic symptoms and headache. 
Quite puffy. January 11, 1858. — A convulsion. Bled by 
Dr. Bolton, with great benefit, who consulted me regarding 
the case. Urine coagulated by heat and nitric acid, and 
presents microscopically evidences of advanced Bright's dis- 
ease. 252^A. — Called to her suddenly in the absence of Dr. 
B., and drew oft* half a chamberful of urine. Same ap- 
pearances. In consultation, prematm-e labor decided upon. 
Felruary 3, 1858. — The day fixed for the operation. Patient 
naturally delivered during the night of a still-born child 
without any difficulty. Chloroform given by Dr. Bolton, 
who was in attendance. March 12, 1858. — General condi- 
tion very satisfactory. Puffiness gone. Dr. B. has fully 
explained to the husband the nature of his wife's disease, and 
given it as our opinion that another pregnancy would be 
dangerous in the extreme. August 16, 1858. — Complains 
tliat she sees every thing divided in four parts. Enchanted, 
however, with her condition, because a late well-known phy- 
sician of this city had seen her while out of town, and, after 
hearing the history of her case, examined some mine for 
albumen, and, not finding any, told her that she would un- 



6q obsteteic CLrcsic. 

clonbtedlj do well. This gentleman snbseqnentlj told me 
himself that he had made no other examination. 

June, 1859. — Dr. Bolton left town and consigned this lady 
to my care. To my great regret, I found her far advanced 
in pregnancy ; not at all apprehensive in consequence of the 
opinion jnst alluded to, and which I then learned for the first 
time. The urine was albuminous, and microscopical exam- 
inations by Drs. Gouley and Alonzo Clark confirmed the 
diagnosis of advanced Bright's disease. Jime Slst. — She was 
attacked with hemiplegia of the right side, with loss of con- 
sciousness. The attack was a mild one, and she greatly im- 
proved. Spirits unimpaii-ed. I now desired to induce prema- 
ture labor, but did not consider it advisable to bring it on 
until her nervous system had recovered more thoroughly from 
the shock, and the risks of recmTino; cerebral hsemorrhao-e from 
the same site had diminished. July 9th. — Patient's condition 
greatly better. Sat up in bed, and took her supper cheerfully. 
Toward morning I was called, and found her with a second 
attack of hemiplegia. Capable of being moved, but other- 
wise sleeping soundly and breathing stertorously. aSo 
convulsion. Dr. Cheesman called in consultation. On the 
10th, seeing that the case was hopeless and the foetal heart 
still beating, I introduced a sponge-tent through the cervix 
uteri, which was rigid, although somewhat dilated — as was to 
have been expected in the fifteenth pregnancy — and visited her 
frequently to take the first opportunity of delivering when- 
ever the OS might be sufficiently dilatable. 11th. — Dming 
my absence she suddenly died. I arrived in a few moments, 
and delivered rapidly by version. Cranial presentation. 
Child still-born. Only two hours before, the operation was 
rendered impossible by the non-dilatability of the cervix. 
ISTo post-mortem permitted. Ko physical signs during life 
of disease of the heart, lungs, or liver. 

, The Induction of Labor as a Prophylaxis. — From the pre- 
ceding remarks it is evident that there is no absolute physical 
sign, on which we can alone rely, to decide the question 



PEOPHYLAXIS OF PITEEPEEAL ECLAMPSIA. 39 

wlietlier prematiu'e la"bor sliould be brought on or not. The 
decision rests on the snmming np of the whole case ; and the 
operation is therefore to be postponed if possible, nnless the 
term of pregnancy be already reached, when we are entitled 
to a larger liberty, with the present excellent methods at onr 
command. 

As in all elective operations, we are liable now to regret that 
it has been postponed too long, and then to question whether 
it might not better have been deferred. Unless the decision 
be arrived at on acconnt of existing eclampsia or other serious 
contingency, if the result be not satisfactory, hostile criticism 
will not be withheld. And if it be satisfactory, and both lives 
be saved, it may be suggested that the operation was unne- 
cessary, meddlesome, and hazardous. Such is the world ; and 
hence the question should be decided in deliberate consulta- 
tion, and the burden divided among strong shoulders. 

My experience leads me steadily to look more favorably on 
the induction of premature labor, in cases where repeated 
examinations of the urine show that the conditions of dis- 
ease are persistent, or progressing despite treatment ; where 
some of the prodromata of eclampsia — the first mutterings of 
the coming storm — are present ; and where the foetus is fully 
viable. In cases where the foetus is not viable, we must wait 
until the mother's life is actually endangered by successive 
attacks of eclampsia, or for other conditions recognizable in 
consultation, which lead irresistibly to the clinical conviction 
that either the pregnancy or the woman's life must be 
terminated. 

In the following case the question of premature labor re- 
ceived my most serious consideration, and it was postponed 
because the patient seemed to improve ; a fact which I have 
since regretted. 

Case 13. — Puerperal eclampsia i indicction of lalor ; 
forceps / Barnes'' s dilators. 

Mrs. had been under my care in her first pregnancy, 



40 OBSTETPwIC CLIXIC. 

when the hibor Tvas tedious, but terminated natni-aUv. Diu'- 
ing that pregnancy her condition gave me some shght ap- 
prehension, and led to frequent examinations of the urine, 
which, however, was always up to the standard of health. 

TThen she came under mj observation in the second preg- 
nancv, her m'ine was found to be albuminous ; sufficient in 
quantity, with casts not numerous, but varying considerably 
in diameter, and either o;ranular, or containino^ shrivelled 
degenerate gland-cells. The specific gravity averaged about 
1014 to 1015. There was occasional dimness of vision, 
seeing objects as through a fog or mist, some disturbances 
occasionally of hearing, as though loud, sudden noises were 
heard. The mine was examined by Drs. A. Flint, Jr., and 
W. H. Draper. The treatment was addressed to the bowels 
and skin. The legs were markedly swollen. The induction 
of labor was considered from day to day, and postponed 
from the thought that the patient seemed to improve. 

June 1, 1S66, she was on her way to bed at a quarter 
of ten in the evening, when she was taken with her fii'st con- 
vulsion. A second one, severe and well marked, occm-red 
at eleven o'clock, and was witnessed by Dr. Crane and my- 
self, and we sent for Dr. W. H. Draper. There was no re- 
turn of consciousness, and we bled her to 3 vi. The patient 
was very strong and plethoric. Consciousness did not return, 
and we decided to bring on the labor. Tlie smallest-sized 
Barnes's dilator could only be introduced. This was dilated 
to its fullest capacity with difficulty at 12 p. ic. June 2d, 2 
A. M. It slipped out. Yiolent convulsion. Labor -pains. Os 
fidly enough dilated to admit the forceps for dehvery from 
the brim. Foetal heart beating. Eight occipito-iliac posi- 
tion. I applied the forceps within the cervix, and delivered 
a living child, which did well. 3 A. :m. Placenta came 
away well. Good uterine contraction. Chloroform had been 
kept up since 11 p. m. 3J- a. 31., 1th. Severe com^ilsion. 
Coma and duskiness of surface very marked. Y. S. ad 3 vi. 
Hyd. chlor. mitis. gr. v. Pulv. jalaps gr. xv. 7 a. it. Con- 



PROPHYLAXIS OF PUEEPERAL ECLAMPSIA. 41 

Yiilsion. She lived until the afternoon of the 3d June with- 
out regaining consciousness. The bowels were freely acted 
on by the medicine. Her strength was sustained by milk 
and beef tea given vrith pepsine. We thought that the ten- 
dency to convulsions was checked by the internal exhibition 
of chloroform in milk. Some hours before her death she 
evidently swallowed with more difficulty. 

Some urine drawn after the convulsions had commenced 
was examined by Dr. Flint, Jr. It presented similar ap- 
pearances to the others, and also some waxy casts. 

Permission was obtained to examine the kidneys alone. 
In doing so, the liver was observed to present marked evi- 
dences of fatty degeneration, and to be very friable. The 
kidneys were examined microscopically by Drs. Flint, Jr., 
and F. Delafield, and the result expressed in the following 
words of Dr. Flint, Jr. : 

" Cortical substance pale, yellowish, and friable. Pyram- 
idal substance unusually red. 

" Co2iwal. — On microscopic examination with the binocu- 
lar and one-fourth inch objective, the following appearances 
were observed: 

" The Malpighian bodies were nearly natural, the convo- 
luted vessels in their interior less prominent than usual, and 
in many of them there were numerous large granules and 
small globules of fat. The convoluted tubes presented granu- 
lar contents, in which it was inipossible to make out any dis- 
tinct division into cells. Some of these contained a few 
granules of fat rather smaller and less numerous than those 
in some of the Malpighian bodies. Nearly all of the cells 
observed floating in the field were filled with small dark 
granules. There were no free oil-drops or granules observed. 
Most of the tubes presented the characteristics above de- 
scribed, but more than half of the Malpighian bodies were 
free from granules of considerable size. 

''^ PyTcvmidal. — In this substance the tubes were often 
found entirely empty. Those which were isolated and full, 



42 OBSTETEIC CLENIC. 

contained dark granular matter. Several waxy casts were 
observed. The free cells floating in the field were generally 
filled with dark granular matter. 

" There appeared to be a want of cohesion in the cortical 
substance, the tubes having a tendency to break up, and 
being isolated with difficulty. In the pyramidal substance 
the contents of the tubes were easily forced out, but did not 
form regular casts in the field, as is usual in a healthy speci- 
men." 

In the following case the question of premature labor was 
a debatable one. The report is taken from the minutes of 
the I^ew York Pathological Society for the stated meeting 
ofJSTovember 11, 1864. 



Case 14. — Alhitininuria i hydro-ne^hrosis of one Mdney j 
distended ureter j arachnitis. 

Dr. Elliot presented a pair of kidneys taken from a mul- 
tipara, who entered Bellevue Hospital on the Thursday be- 
fore. At the time of her admission she was in the eighth 
month of ]3i'egnancy with her sixth child. She never had 
trouble with previous confinements. She was exceedingly 
drowsy, and answered questions very unsatisfactorily. As 
the result of persistent questioning, it was ascertained that 
she had suifered from dizziness during a j)revious pregnancy, 
and that a few years ago she had been subject to a puffiness 
about the face and hands in the morning. The pulse was 
100, and quite feeble. The left pupil was somewhat dilated, 
and contracted sluggishly under the influence of light, as 
compared with the other. On the Sunday before, while 
rising from the breakfast-table, she became suddenly para- 
lyzed on her left side ; sensibility of the side was very defec- 
tive ; tickling of the foot, however, produced the customary 
jactitation. The urine presented a moderate amount of al- 
bumen, and had a specific gravity of 1020, and was normal 
in color. Examined microscopically by Dr. Francis Dela- 



PE0PHTLAXI3 OF PUEEPEEAL ECLAMPSIA. 43 

field, it sliowed no evidences of casts, btit there was a con- 
siderable amount of blood present. The nrine dribbled from 

her, the bladder not being distended, and the secretion was ^ jl 

caught by a cup placed between the thighs. The os was 
dilated to the size of half a dollar, but not dilatable.- The 
foetal head could be detected within the os, presenting in the 
fii'st position, the summum of intensity of the foetal heart was 
upon the left side. 

On the suspicion that the case might be one of ursemia, 
and threatening convulsions, the necessity for inducing pre- 
mature labor was seriously considered. A saline cathartic 
was administered on Thursday with the eifect of brightening 
her intellect on the day following. There was, however, 
still a good deal of jactitation present, though this condition 
was not persistent. On Saturday she was so much improved 
that it was decided to defer the induction of the premature 
labor, in hope that the case was not so serious as was first 
supposed. It was then thought that the bloody urine might 
be due to simple congestion of the kidney, and in that view 
Dr. IMola, the house physician in charge, was directed to 
apply wet cups to the lumbar region, and in case she bore 
the remedy well, to apply them also to the back of the neck. 
Dr. Mola came to the conclusion very properly, after the 
first application of cups, not to repeat them. The patient 
passed the night as usual, and in the morning, by the help 
of the attendant, was able to sit up in bed. Shortly after 
she lay down, and without any warning the liquor amnii 
escaped, followed by the child; and when the nurse, who 
was only a few feet chstant from her, came to the bed, she 
found the child, placenta and all, between the thighs of the 
patient. Some clots followed ; firm pressure was made upon 
the uterus ; and Dr. Mola being sent for, arrived immedi- 
ately. Dr. Mola found the uterus well contracted, and im- 
mediately resorted to the best possible means to guard against 
hemorrhage. WTien Dr. Elliot saw the case in the course of 
the day, she was breathing automatically, and died soon after. 



44 OBSTETRIC CLDsIC. 

Autopsy. — The head bemg examined, there was an nndue 
amonnt of sub-arachnoid fluid. The arachnoid membrane 
was opalescent. The two lateral yentricles also contained 
an abnormal amount of fluid. The choroid plexus was pale. 
About the fissm*e of Sylvius there was evident softening of 
the brain substance. There were slight adhesions in the 
chest, and there was also fluid in the pericardium. The 
right kidney, weighing about fom- ounces, contained a cavity 
occupied by a whey-like fluid, while the walls of this cavity 
were extremely thin, reducing the organ almost to the con- 
dition of a multilocular cyst. The m^eter leading from the 
kidney was also fllled with the same material, and was in- 
creased in calibre. This tube being cut off a short distance 
below, was not followed further. In one of the pouches of 
the kidney was found a small renal calculus. The other 
kidney weighed seven ounces and was perfectly healthy, 
being abundantly able, to all appearance, to perform the ex- 
cretory function allotted to it. 

Case 15. — PuerjpeTal eclampsia / safety of mother and 
child ; induction of labor j history of subsequent labor. 

Dr. Warner sent for me in February, 1860, to a case of 
puerperal convulsions, associated with albuminm^ia, in a 
primipara, occm'ring toward the end of pregnancy. Before 
my arrival she had been leeched and pm-ged. Labor had 
not commenced. We agreed that sponge-tents shoui d be used, 
and tlie patient delivered with forceps as soon as possible. By 
these means Dr. Warner brought on the labor, and delivered 
the woman of a living child, which is now living. 

Within a year this woman became enceinte again. She 
had not been able to nurse the first child, and during the 
earlier months of pregnancy the urine became again albu- 
minous. By enjoining abstinence from meat diet, and the 
use of Bochelle salts. Dr. Warner carried her safely through 
the confinement, the albumen having disappeared before the 



PEOPHTLAXIS OF PUERPERAL ECLAMPSIA. 45 

close of pregnancy. Many months after, cliemical and micro- 
scopical examinations of her nrine gave no evidence of disease. 
She is now (1867) well. 

Case 16. — Albuminuria in a multijpara j premature 
'birth of a still-born jputrid child. 

Dr. C. L. Mitchell requested his patient, Mrs. , to 

call at my office on the 3d of March, 1863, for my opinion. 
History. — Aged 44 ; first menstruation at 15 ; married at 23 ; 
first child in March, 1847; second child in 1850. During 
this pregnancy she suffered much from pain in the head and 
bloating. She was bled, and within twelye hours labor set 
in, and a premature seven months' child was born. At the 
close of her third pregnancy she made a misstep, and hemor- 
rhao^e set in. The hemorrhao^e subsided and returned in a 
month, when she was delivered with forceps of a dead child. 
A miscarriage was followed by two normal confinements, and 
then a miscarriage (attended with much hemorrhage, after 
which she remained " pale and bloated " for some time) pre- 
ceded her present pregnancy. She was last unwell in August, 
1862. Motion felt in January, 1863. During ]^ovember, 
1862, had infiammation of the right lung, and was threatened 
with miscarriage, but saved. Six weeks ago she began to 
notice swelling in her ankles. This has increased and become 
general. Face and hands moderately puffy ; the finger sinks 
deeply over the tibia. Within ten days there has been dis- 
turbance of the sight. Sees objects sometimes as through a 
fog ; flashes of light and sparks before the eyes ; sensation as 
of sand in the eyes ; lachrymation. ISTo disturbance of audi- 
tory nerve. Has " dizzy tm^ns " sometimes in the day. Is 
liable to "a feeling of distress" coming from the umbilical 
region, and spreading over the whole body. Patient not in 
the least hysterical. Some difficulty in passing water, as in 
previous pregnancies ; passed a great deal of water during 
the night before the bloating came on, and since then the 



4^ OBSTETEIC CLDs'IC. 

quantity has diminislied. Still has to rise four or five times 
in the night, but not so frequently as formerly. ISTo nausea ; 
appetite good; bowels natural. Purphsh (vascular) spots 
have recently appeared on the face and neck. 

Dr. A. Flint, Jr., made two examinations of her urine, 
and found the reaction faintly acid. Sp. grav. 1015 ; albu- 
men very abundant. There were scales of pavement epithe- 
lium ; leucocytes in abundance ; granular and waxy casts. 

I recommended abstinence from meat and stimulants, but 
nourishing diet ; leeches behind ears or nape of neck for 
threatening cerebral congestion ; bloodletting if such symp- 
toms showed themselves. Premature labor at time of foetal 
viability, and before if complications occurred. Salines ; 
skin to be kept active ; chloroform for labor. 

On the 15th of April, 1863, 1 received the following letter 
from Dr. Mitchell : 

" I think that Mrs. 's child is dead, and has probably 

been so for a month past. Swelling of limbs has subsided ; 
enlargement has lessened ; and no sign of life has been man- 
ifested. Under the use of the bichloride the crushing pain 
in the head has ceased, the albumen in the urine greatly 

diminished, sleep and appetite much improved 

Trust that all things may terminate more favorably than at 
one time we had promise of." 

On the 18th of April, 1863, Dr. Mitchell sent me the fol- 
lowing note : 

" Mrs. , after a half hour's labor of not over five 

pains, was delivered just now of a foetus that had evidently 
been for a long time dead — at least one month." 

July 8, 1861, the following memorandum was received 
from Dr. Mitchell : 

" In subsequent examinations of Mrs. 's urine, scarce- 

Iv a trace of albumen was found. She is now livino* in the 
country, and, I believe, enjoying excellent health." 

Oct., 1867. " Eemains well." 



PEOPHTLAXIS OF PUERPEEAL ECLAMPSIA. 47 

Case IT. — Alhitminuria and edampsia in the first coiv- 
finement I fersistence of Tenal symjptoms ; induction of 
jpremature labor in second confinement, three years later, 
hy the douche, 

Mrs. was attacked with puerperal convulsions in 

August, 1859, wlien she had reached about the eighth month 
of her fii'st pregnancy. She was bled, and was safely deliv- 
ered a few days afterward without assistance. Chloroform 
was given. Previous to her departure from the city, I had 
made a number of examinations of her urine, both chem- 
ically and microsco]3ically, and these had also been made by 
Dr. Gouley, without the discovery of any thing abnormal. 
Still I requested, if the family should notice any puffiness of 
the face, that some urine should be sent me by express, for 
examination. This was not done, although pufl&ness of the 
face was distinctly observed before the convulsions came on; 
and for many months after her confinement the urine was 
more or less albuminous, and presented granular casts, with 
renal epithelium attached, some of which presented a few oil 
globules. I have made, with the assistance of Drs. Gouley, 
Alonzo Clark, Wm. Henry Draper, and Austin Flint, Jr., a 
great number of examinations of this patient's urine at 
different times, and the result has never been such as to 
make me feel comfortable regarding the risks of a second 
pregnancy. During the interval which elapsed from the 

&st confinement to the second pregnancy, Mrs. was the 

subject of " ulceration " of the os and cervix uteri, with 
leucorrhoea, from which she was entirely relieved by the 
nitrate of silver, vaginal injections, and invigorating treat- 
ment. Iron disagreed with her, and though carefully tried 
in many forms and in small doses, could never be steadily 
relied on as an element in the treatment. The skin was 
always kept warm, warm baths used, and during the first 
winter after her confinement, dry cups were occasionally 
applied over the kidneys, when any pain was complained of 



48 OBSTETEIC CLINIC. 

in that region. In the autumn of 1861 her general appear- 
ance was better than it ever had been — color, appetite, 
strength excellent ; and she became pregnant in the winter. 

Examination of urine by Dr. W. H. Draper, February 7, 
1862. Patient had then been suffering from a severe head- 
ache. (I may mention that the usual phenomena of nausea 
occurred.) 

Morning urine — specific gravity, 1013, and a trace of 
albumen. By microscope, nothing but pus-cells. 

In this instance it was thought that there was enough 
pus to account possibly for the albumen. In the other 
examinations recorded this was not the case. Yery many 
examinations of urine which disclosed no evidences of disease, 
chemical or microscopical, would be of low specific gravity. 

In the beginning of June, Mrs. left town for the 

summer, feeling and looking well ; nor did she suffer from 
any thing unusual until the middle of July, when disagree- 
able but not serious head-symptoms troubled her, and she sent 
nie some urine, which, by mistake, was not examined, and the 
symptoms soon disappeared. On visiting her in the country 
I found her looking well — ^no oedema, puffiness, or outward 
sign of trouble — and obtained some urine, which was exam- 
ined by Prof. A. Flint, Jr., and found to be albuminous," and 
to contain two transparent casts, with some few epithelial 
cells. Two or three oil globules were attached to the casts, 
and one gave a measurement of one-fifteen-hundredth of an 
inch. There were also some crystals of the oxalate of lime. 

Mrs. now came to town, as she had some threat- 

enings of labor, which soon disappeared, and two specimens 
of urine, one evening and one morning, were obtained. 
Both of these were quite albuminous, markedly so when 
nitric acid was added to the urine after ebullition had taken 
place. One was examined by Dr. W. H. Draper, who found 
a specific gravity of 1010, shrivelled, degenerate, renal epi- 
thelium, numerous pale, transparent casts, and a few slightly 
granular, with granular epithelium attached. 



PEOPHYLAXIS OF PUEEPEKAL ECLAIVIPSIA. 49 

Under these circumstances, I decided to indnce prema- 
ture labor. It seemed to me that such was mj duty, for 
these reasons : 

1. The child was fully viable and living. 

2. It was established incontrovertibly that the kidneys 
had never entirely rallied from the albuminuria in the first 
confinement; that they now presented evidences of grave 
disease ; and that there was sound reason for believing that 
these symptoms, which had baffled so much care already, 
would increase in direct ratio to the duration of gestation. 

3. That in addition to the immediate risks to mother and 
child from the efi*ects of the albuminuria, there were the 
greatly increased risks to her future health from the further 
persistence of the causes which had already proved so hurt- 
ful in her first labor, and which were likely to prove so much 
more serious now when the kidneys were weakened by pre- 
vious disease. 

4. That the induction of labor by the douche was not 
dangerous, when properly performed, and ofi'ered the advan- 
tages of greatly diminishing the chances of undilatable os, 
which I believe to be especially liable to occur to women 
who have albuminuria, and who have sufi*ered from long- 
standing ulceration and inflammation of the cervix. 

My opinion was then given to the husband, and my wil- 
lingness to consult with any physician on the subject fully 
set forth. He decided that he did not wish a consultation, 
and that I must act as I deemed best. After waiting sev- 
eral days, during which time Mrs. 's primes vise were 

carefully attended to, the mine remaining unchanged, and 
all parties consenting, I gave the first douche on the 30th 
July, 1862, at about 5 p. m. At this time the os was high 
up and far back, not dilatable, barely admitting one finger. 
The vagina was not at all relaxed, and rather dry. The 
foetal heart was audible everywhere, though less so on the 
left side, where it was masked partially by the uterine souffle. 
Thus I could not satisfactorily determine the site of the sum- 
4 



50 OBSTETEIC CLmiC. 

muin of intensity. The liead was distinctly recognizable 
through the anterior wall of the cervix, a suture being also 
distinguishable. I injected about five-sixths of a large 
pitcherful of warm water, with Davidson's syringe, against 
and within the os, which was dilated enouo-h before the con- 
elusion to allow me to corroborate my diagnosis of the presen- 
tation ; and the opportunity was embraced of drawing down 
the OS so as to bring it more readily within reach of the 
douche, and to increase the prospects of its dilatation by the 
descent of the membranes. Labor-pains set in promptly, 
and continued through the night, so as to prevent her from 
sleeping. At 5 a.m., July 31st, I made an examination, 
and found that the right thigh was now across the os uteri, 
this latter being larger than a dollar, and dilatable; mem- 
branes unruptured. The knee was to the left side of the os, 
the ilium within reach of the finger introduced within the 
cervix on the right side. The head could be felt in the epi- 
gastric region. Foetal heart beating. This disagreeable 
complication had been alluded to by me in a conversation 
with Dr. Thomas before the labor, as a contingency more 
likely to happen in a prematm-e labor, though certainly it 
surprised me none the less when it occurred. 

When living in the Dublin Lying-in Hospital, in 184:9, 
in a case of deformed pelvis, the head was perforated ; after 
a consultation by Dr. Shekleton with Johnson, the former 
Master, Evory Kennedy, George Johnston, Collins, McClin- 
tock, Harrison the anatomist, and Sir Philip Crampton, it 
was decided to let the head remain a couple of hom-s to 
mould itself to the brim. At the expiration of this time the 
head had gone up on the right side of the uterus, and the 
arm was found in the vagina. 

Such a ^^ cuTbute^'^ or "rope-dancer's trick," as Hunter 
called it, as happened here, has not occurred in my experi- 
ence, though much more striking ones are recorded by the 
best authorities ; perhaps no one more so than that recorded 
by Depaul in his " Traite d' Auscultation Obstetricale," 



PEOPHTLAXIS OF PUEEPEEAL ECLAMPSIA. 51 

Paris, 184:7, page 318, wliere Depanl, Madame Calle, sage- 
femme en chef, Dubois, and Cazeaux recognized by tbe 
toucli that, in a woman eight months and a half gone, the 
head was recognized to present in the morning and the feet 
in the afternoon ; and some time later in gestation the head 
again presented, and the delivery was then effected. In 
that case, these variations in the presentation were not caused 
by uterine contraction. In my case the alteration was not 
effected by the douche, for I felt the head after that was 
completed, and I do not know the stimulus for the reflex 
action. ]\Iy patient was now quite restless and excitable for 
one possessing such a remarkable degree of self-control ; and 
I concluded to put her under chloroform, give another 
douche, and see what had best be done. Accordingly I 
sent for Dr. Thomas, who arrived about 7 a. m., when, after 
she had been brought under the influence of chloroform, he 
came into the room and kept up the ansesthesia. Having 
placed her in the obstetric position, and confirmed my diag- 
nosis of the new presentation, I proceeded to endeavor to 
turn ly external manij)ulation, and succeeded in changing 
the position so far that the finger, well introduced on the 
right side, within the cervix, touched the knee in the place 
where the ilium had been. But this was the extent to 
which the version could be effected, and I accordingly re- 
placed the thigh by pressure through the right side of the 
uterus, and fully dilated the os by a small douche and the 
use of my fingers. She was then replaced in bed, and the 
chloroform kept up. In about an hour the membranes 
broke and the right knee came near the vulva, when we 
again replaced her in the position for forceps; and these 
being ready, but not needed, I succeeded in delivering a 
living, well-formed male child, weighing about seven pounds, 
without the loss of a moment. The cord was three times 
around the neck, and was rapidly disengaged. The child 
seemed at first indisposed to breathe, but the cord pulsated 
well, and after much less than the customary efibrt in such 



62 OBSTETEIC CLINIC. 

cases, we considered tliat lie would do well. He was 
dressed, broiiglit to receive the mother's kiss, and when 
I went to breakfast at eleven (leaving the sluggish uterus 
to Dr. Thomas's care, as it still required holding), I had 
the happiness of feeling that the case had proved a per- 
fect success. The nm-se then sent for me to say that the 
child was blue, and on examination we feared the worst. 
The right leg, thigh, and arm were bluer than the others, 
but the marks of universal dermoid congestion were every- 
where apparent. The respiration was feeble in inspira- 
tion and prolonged in expiration ; the epigastric pulsation 
unduly marked, and attributed with correctness by Dr. 
Thomas to the engorged right side of the heart. Some 
comparative dulness was apparent in the left chest anteriorly. 
Stimulus by enema, as the child would never swallow; 
friction, warm and cold baths, sprinkling, and the persistent 
use of Marshall Hall's method for some hours, would rally 
but not permanently benefit the child. We sent for Dr. 
Jacobi. He examined the child with his accustomed thor- 
oughness, and stimulated the cutaneous nerves with great 
vigor, and with the effect of very markedly arousing the 
child for a time ; but, as before, the letliargy and the pro- 
longed expiration returned, and the child died between five 
and six in the afternoon, with a steady advance of all symp- 
toms, except the coloration of the face, which became quite 
pale. The eyes opened an hour or two before death for the 
first time. 'No squinting, no paralysis. 

Autopsy. — Twenty-two horn's after death ; weather quite 
warm. Blue coloration marked, except in the hands, which 
were white, the blood having left them by gravitation, as 
they were folded on the abdomen. Lungs congested, highly 
colored, collapsed. Left lung felt as though it had never 
been inflated in the upper lobe. They were readily blown 
np with the pipe. Pleurae, heart, and vessels, and pericar- 
dium normal ; liver congested but normal, as were the other 
viscera. Brain and medulla examined with great care, and 



PEOPHYLAXIS OF PUEKPEKAL ECLA3IPSIA. 53 

witliout result. Blood examined for Tirea, without re- 
sult. 

Mi's. remained weak, with a sluggish uterus, some- 
what restless, clear-headed. Beef tea, brandy, and ergot 
through the day; codeine at night. Catheter that night. 
August 1st. — Beef tea and oatmeal gruel. 'No stimulus. 
Codeine. Good night. August 2d. — Yery comfortable day ; 
codeine. Good night. August Sd. — Enema. Some clots. 
Breasts distended with milk. Since that time her conva- 
lescence was uninterrupted. She has subsequently suffe*red 
from a return of the old erosion of the cervix with uterine 
catarrh, for which she was treated for two or three months 
with perfect success. Since then she has done uninterrupt- 
edly well ; her mine has returned to the normal standard. 
No pregnancy has occurred. She is now (July, 1867) in 
excellent health. 



Case 18. — Puerjperal eclampsia j induction of labor ^ 
Barneses dilators; douche ; forcejps ; chloroform. 

At 11 A. M., December 13, 1866, Drs. Leverich and Yan- 

derveer sent for me in consultation in the case of Mrs. , 

a primipara, aged twenty-two, suffering from puerperal urse- 
mic eclampsia. She was well-formed, and healthy-looking, 
without oedema, and no paler than might have been expected 
in a case where blood had just been taken by leeches. 

She had been married eleven months, and had menstru- 
ated for the last time eight months ago. On the 28th of 
jSTovember last she had been attacked with convulsions under 
the care of the same gentlemen, and had been treated by 
wet cups to the temples ; purgatives ; and counter-irritation to 
the spine. In all she had seven perfectly well-marked con- 
vulsions, consciousness returning between the first and sec- 
ond, and then remaining in abeyance until the attacks ceased. 
The urine was found to be very markedly albuminous. Un- 
der the treatment employed the convulsions ceased, the pa- 



64: OBSTETEIC CLLN-IC. 

tient was restored to consciousness, and tlie pregnancy vras 
allowed to progress. 

On December IStli, at 7 a. m., she was again attacked, 
after liaving vomited and pui'ged moderately through the 
night. Four convulsions had occm-red before my arrival, 
with a retmTL to consciousness between the first and second. 
Six leeches had been applied to the temples, which were jet 
bleeding ; counter-imtation had been used to the spine, and 
assafoetida had been given by the rectum. Just after my 
arrival another perfectly characteristic convulsion recurred. 
The uterus was not large, patient evidently not at term — ^ap- 
parently about seven months. Cervix uteri very high up, and 
admitting one finger ; head presenting, membranes unrup- 
tm*ed, vagina not relaxed. Iso labor-pains. Xo foetal heart 
or uterine souffle. Xo fcetal movements. Pulse before the 
convulsion, and dm-ing the rest of the day, very rapid and 
very feeble. Surface cool. 

It was agreed that the condition was one of extremest 
danger, that the child was dead, and that the mother's best 
chances were founded on her deliveiy. "With the appro- 
val of all, I determined to tiy Barnes's dilators. The 
patient's condition was such that we were unwilling to 
give chloroform ; and I found the task very arduous on ac- 
count of the physical difficulties described in the vaginal ex- 
amination, and on accoimt of that extreme jactitation which 
we often see in these cases of puei-peral albuminmia, and 
which is such an unfavorable symptom, ^j third effort was 
successful, and the second size was squeezed into the rigid 
cervix, an operation only rendered possible by the aid of a 
catheter, after all the air had previously been expressed from 
the dilator. Carefully proceeding to inject the water, the 
dilator was suddenly and completely sucked within the ute- 
iTis to such a distance that I could not touch it thi-ough the 
cervix, and was apprehensive for a moment that, if the hol- 
low supply tube should give way, the instrument might only 
be delivered after the child. However, after the water had 



PEOPHTLAXIS OF PUEEPEEAL ECLAMPSIA. 55 

been allo\red to escape, careful tractions drew it in the va- 
gina. Managed to reintroduce it with great difficulty ; when, 
on injecting the water, a leak occurred at the base, wliich 
rendered it useless. J^ot to dwell too long on the peculiar 
difficulties that attended the dilation of this remarkably rigid 
cervix, it may be said that if then and subsequently the dila- 
tor was well introduced into the cervix, it would be sucked 
into the uterus ; and if it were not well introduced, it would 
be thrown into the vagina.' Another peculiarity occm-red in 
the case. When some dilatation had been gained, and the 
instrument thrown out, as described, the cervix contracted, 
and felt, as Dr. Leverich remarked, like a band of hard 
rubber. 

Having sent for new dilators, I ruptured the membranes^ 
drew off some urine, and waited. When they came, at half- 
past two, I renewed my trials, placing the woman both on 
her back and on her left side, with the results detailed. La- 
bor-pains, however, commenced at Rye o'clock, and some ad- 
vance had been made, as the cervix now admitted two ffii- 
gei*s, with an edge that felt like whip-cord, and was utterly 
undilatable. Meanwhile, three more convulsions had hap- 
pened. At half-past five I injected two large pitchersful of 
warm water against the inner rim of the cervix, having pre- 
viously left the largest-sized dilator in the vagina for an hour 
or two, as a stimulant to uterine contraction. At half-past six 
and half-past seven these injections were repeated by Dr. 
Leverich ; and at 8 p. m. the cervix would admit the points of 
three fingers, but was as rigid as ever. It was decided that the 
perforator should be used, and the patient was kept quiet by 
chloroform given by Dr. Yanderveer. Having opened the 
head, and evacuated the foetid contents, I drew with Church- 
ill's crotchet cautiously. The cervix followed down the 
head and the shoulders to within an inch of the vulva, and 
demanded counter-pressure with the hand, which also guard- 
ed the crotchet. The child was a female, putrid and small. 
Placenta came away readily. Two more convulsions had 



56 OBSTETEIC CLINIC. 

occiirred since the last note. Ergot was given, and, as tlie 
patient was very feeble, an enema of beef tea and brandy 
was injected, and held up. During the day there had been 
long intervals in which she conversed with those in the room, 
bnt I donbt whether consciousness was complete. 

Some mine carefully drawn with the catheter was examined 
by Prof A. Flint, Jr., with the following result : " Eeaction 
acid. Albumen very abundant, with urates, which cleared 
up on the first application of heat. On microscopical exam- 
ination I found mates, fatty granules and globules, and casts. 
The casts were more numerous than I had ever seen them. 
They were granulai', large and small, and waxy. The large, 
half-granular and half-waxy casts seemed to predominate. 
There was not enough for specific gravity." 

In July Dr. Yanderveer informed me that this patient had 
continued to improve and do well since her confinement. 

Varieties of Puerperal Conwisions. — We need a term to 
distinguish such convulsions in a puerperal state as are general 
in chai-acter, with total abolition of consciousness, fom those 
which are more or less incomplete, and of less dangerous sig- 
nificance. Hence the term eclampsia is as good as any other 
for the former, and the latter can be assigned to thek special 
causes, so far as these are understood. 

The following case is unique in my experience : 

Case 19. — Puerperal convulsions unconnected with 
evidences of renal disease ^ consciousness not abolished y 
chloroform^ douche. 

Susan Mabbett, aged 33, entered the Xew York Lying-in 
Asylum, May 18, 1853, when I was Eesident Physician, and 
four days before her ninth confinement. Her expression is 
haggard, teeth very bad, and general ex]3ression that of im- 
paired health. For the last ^\q years she has suffered from 
convulsions, which are increasing in severity and frequency. 
She has once miscarried, but has not been confined since her 



PEOPHYLAXIS OF PUEEPEEAL ECLAMPSIA. 57 

liability to coiivulsions. Her feet are not swollen, and her 
urine contains no albnmen, but great quantities of the urate 
of ammonia, with some m-ate of soda and bile. Her appetite 
is capricious and her digestion bad. She is liable at all times 
to convulsive jerks of the body, springing from the lumbar 
region as a centre, and which can be determined at any time 
bv pressm-e on these vertebrae. On the 19th, at 3 p. m., she 
had a severe convulsion, followed within an hour and a half 
bj seven more. A description of one may serve for all : The 
jerking movement alluded to commenced, resisting all her 
efforts to control it ; her eyes then turned to one side, with a 
wild, severe expression ; lips tightly closed. I desired her to 
look at me, and she replied with evident difficulty, "In a 
minute ;" then her body stiffened itself, with her head and 
legs thrown back, arms stretched from her sides, with her 
hands tightly clinched and flexed, and the convulsive jerking 
movement increasing in rapidity ; suddenly she bent her head 
forcibly on her breast, drawing several deep inspirations with 
a loud, harsh noise, and then resuming her original position, 
with her head moving convulsively from side to side. Some- 
times she would flex her head on her breast more than once 
during the attack ; but then only did she appear to inflate 
her lungs ; her tongue protruded occasionally, but she did not 
bite it ; and when the fit was over she would lie exhausted, 
but free from anxiety, though anticipating its return. At the 
time she appeared most convulsed I closed one eyelid, and on 
learning from her afterward what had been done, I was sure 
that she had not lost consciousness. The os then commenced 
to dilate, and the head presented in the first position ; foetal 
heart audible ; pains rather good ; there was no positive indi- 
cation except the use of an ansesthetic, and I thought it as 
well to watch the attacks in the hope of their cessation ; but 
at last I exhibited chloroform. She came readily under its 
influence, and revived readily. I have since had occasion to 
beheve that she had been in the habit of drinking. I kept 
her an hour under chloroform, when I allowed her to revive, 



68 OBSTETEIC CLINIC. 

the pains still continning. Slie then had a quiet sleep. 
During the evening ghe had a less severe attack, in the pres- 
ence of Dr. Metcalfe, and passed a quiet night. On Friday 
the OS was dilated to the size of a dollar, thick and unyielding. 
During the afternoon she became rather wild, insisting that 
her sister was in the closet, and at one time shrieking fear- 
fully. I quieted her without chloroform — soothed her, and 
persuaded her to control herself. She again passed a pretty 
comfortable night ; at times the pains would be well marked 
for two or three hours, and then cease. On Saturday, at 
2 p. M., finding the os still unyielding, I determined to try 
the effect of Kiwisch's douche, and injected a half-pailful of 
warm water in a steady stream against and within the os. 
I used Higginson's syringe, injecting with one hand and 
guiding the tube with the other, and never derived a better 
result. The os softened — melted away. The pains increased 
steadily in frequency and force, and within three hours she 
gave birth to a living female child. Placenta came away 
readily. She needed no further treatment except profound 
quiet and well-regulated nourishment, and left the house on 
the 3d of June. 

The following case illustrates the severe hysterical type 
of convulsions, though not occurring in the puerperal state : 

Case 20. — Hysterical convulsions and hemijplegici. 
Bellevue. — Dr. J. B. Buist, House Physician. 

Hannah — — came under my observation March 4, 1858, 
as she lay in bed in an exhausted condition, apparently 
unconscious, but capable of being roused and of answering 
questions. She was unmarried, well formed, healthy looking, 
and had no menstrual irregularity. For two weeks she had 
been troubled with severe pain in the head, circumscribed in 
a spot about two inches square over the right fronto-parietal 
suture, for which she had sought relief in constant cold lotions. 
At the end of this time she complained to her fi'iends of a 



PEOPHTLAXIS OF PUEEPEEAL ECLAJSIPSIA. 59 

numbness and weakness in tlie left hand, extending up tlie 
arm. Three days before admission she was seized, after 
retiring, with a strong epileptiform fit ; both sides affected ; 
foaming at the month ; tongue not bitten. When this had 
ceased her left side remained paralyzed. She declared then and 
subsequently that she was imconscious from this period until 
her admission. It is certain, however, that the convulsions 
had continued, and that the left side was chiefly affected in 
the attacks. Presently, while I was watching her, she had 
a well-marked convulsion, without protrusion of the tongue, 
great suffusion of the face, stertor, loss of consciousness, or 
foaming at the mouth. The character of the convulsion was 
hysterical. Chest normal ; bowels confined ; urine normal ; 
no signs of paralysis about the face ; tongue protruded in a 
straight line ; sensibility of left side unimpaired, though 
there was loss of motion, which was absolute during the con- 
vulsion ; pulse 56, with well-marked intermission every fourth 
or fifth beat ; respiration slow. These convulsions were very 
numerous indeed. On the following day, a drop of croton- 
oil was given by Dr. Buist, in half an ounce of castor-oil, 
and a blister applied to the nucha. On the 6th, as there had 
been no action from the bowels, an ounce of Epsom salts, fol- 
lowed by a warm enema, was given without relief. In the 
evening she was passing her urine involuntarily. I ordered 
one drop of croton-oil and four grains each of calomel and 
podophylline, which brought away several dark and offensive 
stools the next day. 

At this time the diagnosis was obscure — ^her condition 
was such — convulsions constantly recurring, hemiplegia per- 
fect, strength feeble, and expression bad — that it seemed 
inhuman to dwell upon hysteria, though the convulsions, 
which I had frequent opportunities of showing to the class, 
were uniformly of the character described. Under these 
circumstances, I requested Dr. Clark to visit her, who thought, 
T\dth me, that time was a necessary element in the diagnosis. 
After evacuation of the bowels the pulse had risen to 80^ and 



60 OBSTETRIC CLmiC. 

the coiiYiilsions became less frequent, and in tlie evening slie 
seemed better, and more rational. Four leecbes were applied 
over tlie painful spot elsewhere described, and wliich was so 
suggestive of hysteria. 15th. — She has remained pretty 
much in the same condition. Control over the bladder now 
regained. Convulsions no longer affect the right side. Yol- 
untary motion of the leg has been regained, and she is now 
able to raise her left arm. Ordered one grain of the vale- 
rianate of iron three times a day. 19th. — Has improved so 
rapidly that she can now walk the ward without assistance. 
Since this time she has continued to improve, and did well. 
The following case likewise presented convulsive move- 
ments from the poisonous effects of stramonium in a well- 
marked manner. In the case of the boy referred to, the seeds 
had been picked by the little fellow in a garden in this city. 
The cases bear on the differential diagnosis : 

Case 21. — Poisonous effects of an infusion of stramo- 
nium-leaves injected in the rectum, j recovery j subsequent 
conception. 

Mrs. , aged 22, of slender build, but of average 

health, had, however, menstruated rather profusely for some 
years before marriage. Subsequently to that event she con- 
sulted me for great pain in the back, ii'ritable bladder, with 
difficulty in passing water, and trouble in defecation as though 
from some obstacle. On vaginal examination I found a ute- 
rus of normal size quite retroverted, and presenting a slight 
patch of abrasion around the os. A full-sized sound could 
be readily introduced to the fundus, and restoration of posi- 
tion effected, and with some little attention in the way of sub- 
sequent reposition, and a few applications of the nitrate of 
silver, these symptoms (which had been of recent date) disajD- 
peared. Irritabihty of bladder and nem^algic pains would occa- 
sionally demand relief on subsequent occasions, but the dis- 
placement was never reproduced. Benzoic acid internally, 



PE0PHTLAXI3 OF PUEEPEEAL ECLAMPSIA. 61 

and au occasional opiate vaginal snppositoiy, were generally 
successful. Kineteen months of married life had thus passed, 
with but one ungratified wish — viz., for children. In May, 
1860, I was consulted one Sunday for constipation and some 
wandering pehdc pains, and ordered some laxative pills, and 
some two-di*achm packages, containing in all 3 iv. of stramo- 
nium-leaves. She was distinctly informed that the pills were 
laxative in character, and that the leaves were to be used as 
follows : viz., half a pint of boiling water to be poured on the 
contents of one package, and the liquid to be poured off in ten 
minutes' time, when it should be used as a vaginal injection. 
She took the pills, and then proposed to her husband to put 
the contents of all the packages in a pint of boiling water, 
and use the tea as an enema. He remonstrated with her, 
and argued that the pills were avowedly given to move the 
bowels, and that there would be no use in dividing the leaves 
in a mmiber of packages, if I had desired that they should 
all be used at once. These arguments not prevailing, he 
went to the drug-store, and inquired whether this tea could 
be used in the rectum, or in the vagina alone ? The apothe- 
cary referred him to me, but said that the remedy might be 
used in the rectum and in the vagina. Still the husband 
positively forbade his wife to use more than one-quarter of 
the tea which had already been prepared from the whole 
four ounces. This amount she then injected in the bowel, 
and came almost instantly into her bedroom, staggering 
wildly, and fell on the bed, unconscious. I was summoned 
hastily, and found her perfectly under the influence of stramo- 
nium; countenance flushed; eyes staring stupidly; pupils 
widely dilated ; muttering incoherently, and unable to reply 
to questions ; restless, uneasy, tossing, throwing herself sud- 
denly forward ; striving to get out of bed ; grasping with her 
hands vaguely, as though under the influence of spectral il- 
lusions ; picking at bed-clothes ; pulse rapid and feeble ; ex- 
pectorating occasionally a thick mucus, without regard to 
where it fell. When allowed to get up, she staggered 



62 OBSTETEIC CLIXIC. 

vaguely in a purposeless manner, and appeared quite blind. 
I gave a large enema to wash away any of the poisonous in- 
jection wMcli might be retained. There seemed to me no 
further indication for treatment beyond the necessity for 
supporting strength, and the question as to the advisability 
of the hypodermic injection of morphia. 'Not being willing 
to assume this responsibility, I summoned Prof. Yan Buren, 
and we then sent for Prof. B. "W". McCready for farther ad- 
vice. Some time elapsed before his arrival, and meanwhile 
the patient had begun to show some improvement and a 
tendency to sleep — from which, however, she would suddenly 
waken every little while, and presented all the sj^nptoms 
described, strikingly like those in the case of the boy poi- 
soned by stramonium-seeds which I have published in the JVew 
York Journal of Medicine. It being agreed not to give 
opium, we left .the patient to the influences of time. She 
remained in a somewhat similar state all the next day, 
though able to speak, but on the following morning slie rec- 
ognized her friends. The pupils remained dilated for a 
week, after which time no ill eflfects were experienced. 

It is an interesting fact, that the next period occurred 
shortly afterward at the regular time, and was foUo^ved by 
impregnation. Whether post or propter hoc I am unable to 
say. She has been confined since that time, in all, with 
three children, and enjoys good health. 



CHAPTER III. 



CHLOEOFOEM AKD VENESECTION m PUEEPEEAL ECLAMPSIA. 

Chloroform in puerperal eclampsia. — Case: Alarming symptoms from chloroform 
in a natural labor. — Case: Alarming symptoms from sulphuric ether in an 
operation for urethro-vaginal fistula. — Chloroform in cardiac disease and 
syncope. — Case: Syncope after labor, and subsequent history. — Case: 
Powerless labor; delay; cardiac murmur; ether; forceps. — Case: Amy- 
lene. — Venesection. — Case: Puerperal eclampsia ; venesection. — Case: Puer- 
peral eclampsia; forceps. — Case: Puerperal eclampsia; forceps. — Case: 
Puerperal eclampsia; no albumen; forceps. — Case: Puerperal eclampsia; 
venesection; cups; chloroform. — Case: Puerperal eclampsia; venesection; 
cathartics; forceps. — Case: Puerperal eclampsia; chloroform; cups; for- 
ceps. — Case: Puerperal eclampsia ; cups ; chloroform. — Case: Twins ; 
eclampsia; chloroform; Purgatives; cups. — Case: Puerperal eclampsia; 
mania. — Case: Puerperal eclampsia; chloroform; cathartics; emetics; 
venesection. — Case: Puerperal eclampsia; no albumen. — Case: Puerperal 
eclampsia; forceps; normal dilatation. — Case: Puerperal eclampsia. — 
Case: Albuminuria; intra-uterine hydrocephalus. — Case: Bright's disease? 
puerperal eclampsia; chloroform; Barnes's dilators. — Case: Albuminuria; 
eclampsia; death before dehvery. — Case: Albuminuria; eclampsia; death 
from apoplectic clot with atheromatous degeneration of vessels. — Case: 
Albuminuria; eclampsia. — Case: Albuminuria; induction of labor ; mania; 
subsequent history. — Case: Albuminuria; eclampsia; induction of labor. — 
Case : Albuminuria ; eclampsia ; induction of labor ; craniotomy. 

If only one method of treatment were given to me for 
these cases, mj choice would unhesitatingly be for chloro- 
form. The chief indications are, to terminate the labor as 
speedily as may be justifiable, and meanwhile to keep the 
patient moderately under the influence of chloroform. 

In looking over my cases, while recalKng some in which 
the agent was administered unskilfully, I see every reason 



64 OBSTETEIC CLIOTC. 

for believing that chloroform is the most prompt and certain 
agent that we possess for moderating the violence and pre- 
venting the recurrence of the convulsions. 

In this, as in all other cases v^here ansesthetics are used, 
the choice must be made between chloroform and sulphuric 
ether ; and a man's practice is influenced by his familiarity 
with one agent rather than with the other ; by the judgment 
of the consultation, and by the prevalence of opinion in the 
locality where he may chance to practise. 

In general surgical practice, and for general use, there is 
a preference in 'New York for sulphuric ether. Some years 
ago a patient died under chloroform in the surgical wards of 
the City Hospital, and that agent was then banished from 
use in that institution. But since that time another one 
has died there from ether, and this anaesthetic continues to 
be used, from the conviction of the staff, that it is safer than 
chloroform. On the whole it is generally believed in this 
city that sulphuric ether is safer for surgical operations. 
Hence, a man in this city who should have the misfortune 
to lose a patient by an anaesthetic, would have more sympathy 
and approval if he had used sulphuric ether, than if he had 
selected chloroform. 

These influences do not, however, obtain to the same ex- 
tent in obstetrics, for therein chloroform has been shown to 
act reliably, powerfully, and with trifling risk ; while in no 
class of cases are its benefits more apparent than in those we 
are considering. In Bellevue I have lately fallen somewhat 
into the habit of using sulphuric ether in obstetric operations, 
though in my experience the use of this agent in obstetrics 
bears no relation whatever in frequency to thq^ of chloroform. 

The Bulletin of the ^ew York Academy of Medicine for 
December, 1861, contains a report of my remarks on the 
uses of chloroform in obstetrics, in the debate on the valuable 
paper of my colleague, Prof. B. Fordyce Barker, in which I 
see very little to change. Before that time, however, I had 
given sulphuric ether scarcely at all in obstetrics, but since 



chloeofoe:si, etc., in pueepeeal eclampsia. 65 

tlien I have used it in a number of cases. In one I have 
found it better borne than chloroform, the latter agent de- 
pressing the pulse, which intermitted under its use, while 
ether produced a stimulating effect. The labor was natural. 
There is no difference in the effect of ether or chlorofoim upon 
the labor-pains, so far as my experience goes. This stop- 
page of the pains, or diminution of their force, which demands 
that chloroform should be occasionally denied to a patient, 
is produced as readily by ether. In the same labor I have 
several times seen these agents equally and successively 
produce this effect, and the pains improve after each with- 
drawal. Hence the patient has been deprived of their 
benefit,. as the alternative was an operation. In but one case 
have I personally met with alarming symptoms when I 
have given chloroform to a woman in labor. 

Case 22. — Alarming symptoms from, cMorofoTin in a 
natural lahor. 

This happened in a second confinement. In the first the 
lady had borne it admirably well, and had been delivered 
in the country with forceps of a very large and fine boy. In 
the second she came under my care ; every thing promised 
favorably. The dilation of the cervix was going on satisfac- 
torily, the pains not very frequent but efficient, and I ad- 
ministered chloroform at her urgent request. When the 
pains came on I gave a little on a handkerchief, and, 
when they were over, stepped into a dressing-room at the 
head of the bed to look over a book, returning when sum- 
moned by her cry for " more chloroform." On one of these 
occasions I gave her a few drops on the handkerchief, and 
held it, as usual, to her face, when she suddenly stopped 
breathing, and the pulse ran down in a most alarming way. 
I instantly commenced the use of Marshall Hall's method, 
and was relieved beyond measure when she began to breathe 
again. She implored us all to continue the chloroform, but 
she got no more, and has done perfectly well. 



6Q OBSTETKIC CLINIC. 

In the following case the patient came very near dying 
from the effects of sulphuric ether during my service in 
April, 1867; and those accustomed to use anaesthetics can 
well appreciate the anxiety of the situation. The coinci- 
dence of such perfectly-closed jaws, with the entire abolition 
of consciousness, is interesting, and could scarcely have been 
expected if chloroform had been used. 

Case 23. — Urethro-vesical fistula ; dangerous symj^toms 
from suljpTiurio ether as an anmsthetic / coramencing cystitis 
relieved ly the failure of the operation. — Dr. Nicoll^ JJouse 
Physician. 

Elizabeth Wheaton, aged 33; Irish; servant; married; 
has had four children ; two labors very difficult, but not in- 
strumental. 1^0 history of syphilis. Has acne rosacea, and 
syphilis is suspected. Periods began when she was eighteen ; 
menstruation has been irregular. Eleven years ago she 
states that she had prolapsus uteri, resulting from parturition, 
and since that time has been subject to leucorrhoea. To re- 
lieve this complaint she was accustomed to use vaginal in- 
jections, employing for the purpose a glass syringe. Five 
years ago, while injecting herself, she fell and broke the 
syringe, and since that time the urine has constantly escaped, 
except for a few weeks immediately after an operation per- 
formed three years ago. She has had two operations per- 
formed on her during the last year without relief The fis- 
tula is about half an inch in diameter, situated at the junc- 
tion of the urethra and bladder, involving the sphincter 
vesicae, and bounded by cicatricial tissue. 

She was brought under the influence of sulphmic ether 
for an operation on the 20th of April, 1867, having pre- 
viously taken one potato for dinner. The inhalation com- 
menced at 2.10 p. M., and twenty-five minutes elapsed before 
she could be satisfactorily anaesthetized. Five silver sutures 
were used, and the edges carefully brought together in a 



CHLOEOFOKM, ETC., m PUERPERAL ECLAMPSIA. 67 

longitudinal direction, in tlie presence of Dr. Goiiley and the 
house stafl*, by Dr. Elliot, and at 4.10 the patient was carried 
to bed and well blanketed. She had borne the anaesthetic 
admirably, and had vomited a small quantity once. Within 
five minutes after she was placed in bed her pulse ran down 
to 45, and was scarcely perceptible. Respiration 24, 
and regular. Mouth closed, and teeth so firmly set that 
nothing could be given by the mouth. Four ounces of 
whiskey were therefore given by the rectum, and held up ; 
strong ammonia held near the nostrils, and bottles of hot 
water packed by the extremities. Soon after two ounces 
more of whiskey were given by injection, her jaws being 
still closed. At this time she had a short but severe chill. 
By the end of an hour her pulse had imjDroved in frequency 
and volume. She had vomited several times. At 6 p. m. 
her pulse was 72 ; respiration 22, and the mouth could be 
opened. 'No cutaneous sensibility or manifestation of con- 
sciousness. No movement when the conjunctivae were touched 
by the finger. By half-past six her mouth could be opened 
readily, and occasionally she would make an attempt to swal- 
low, and toss her arms about. By eight o'clock she could 
understand when spoken to loudly, and mutter a few words, 
but she was not fully restored to consciousness until mid- 
night. 

It having been decided not to leave a catheter in the 
bladder, the urine was drawn every two hours. During the 
first twenty-four hours it amounted to sixteen ounces and six 
drachms, and was normal. On the 21st, at 5 p. m., she began 
to suffer pain when the site of the bladder was pressed on, 
and had a constant desire to pass water. During the night 
the urine became dark-colored and thick, and it pained her 
when the catheter was introduced ; the pain persisting until 
the instrument was withdi'awn. On the morning of the 2 2d 
turpentine stupes were applied to the hypogastrium ; the bi- 
carbonate of potash and demulcents given ; and the bladder 
was washed out three times a day with warm water. On the 



68 OBSTETEIC CLINIC. 

following clay urine escaped from tlie vagina, and the fistnla 
was recognized to have reopened. 21tli. — Urine drawn witli 
catheter, nearly healthy in appearance. ]!^one has escaped 
from the vagina for twentj-fonr honrs. 

The subsequent history of the case showed the operation 
to have failed, but the relief of the vesical irritation was 
coincident with the reopening of the fistula. 

Cardiac Disease and Syncope. — In cases of cardiac dis- 
ease, and where there is a tendency to syncope, I prefer to 
use sulphuric ether for the reasons given, rather than from 
any belief that there is more danger in obstetrics from one 
agent than from the other. I might be unwilling to give an 
anaesthetic if I believed that marked fatty degeneration of 
the heart were present. Yet I know from my records, that 
I have given chloroform with safety in cases where death has 
occurred from other pathological conditions, and where the 
fatty degeneration was proven by the microscope. Undoubt- 
edly, therefore, it is very often given where this fatty degen- 
eration is not even suspected. There are other conditions in 
which the heart's action is irregular or intermittent from 
functional disturbances, in which, if an anfesthetic had to 
be given, I would prefer to use ether, because the majority 
of our practitioners believe it to be safer. 

The heart should always be examined before an anaes- 
thetic is given, and stimulants should be administered in ad- 
vance if there be debility. Cases of syncope dm-ing or after 
labor, without hemorrhage, or other sufficient cause, may 
be very alarming ; and I suspect that many of them are 
associated with fatty degeneration of the heart ; a condition 
so often difficult to diagnosticate with certainty. This suspi- 
cion is strengthened by the following history. 

Case 24. — Syncojpe after labor. 

Mrs. fell in labor with her fourth child on the Sith 

of March. 1861. Her previous labors have been difficult 



CHLOEOFOEir. ETC., IX PUEEPEEAL ECLAMPSIA. 69 

from the size of her children (which have all been born 
alive), and from the fact that in each case before this one 
the occiput has turned posteriorly. The first child was 
delivered with forceps, by Dr. Metcalfe and myself; the 
other two were delivered naturally. She has taken chloro- 
form in every confinement, in the first for nearly twelve 
hom*s ; and she has also taken it for operations on the teeth, 
and for sick headache. She is a healthy, strongly-built 
woman, with no disease that I can recognize, although she 
has always been liable to a peculiar lividity of the lips, and 
subject to attacks of syncope, which have demanded no espe- 
cial treatment. 

On the present occasion I was called about 8 a. m., March 
25th, but made no examination until after ten o'clock, as I 
knew, from a previous one rendered necessary by false labor- 
pains, that the presentation was natural. At 10 a.m. the 
OS was fully dilatable, membranes imruptured, head passing 
through the brim in the first position. I then left for an 
hour and a half, after forbidding the use of chloroform dur- 
ing my absence, as I was desirous that all the voluntary 
efibrts should have full play. When I returned I found 
that the pains had been very severe, and that the ansesthetic 
had been withheld from her with difficulty. The head was 
now on the floor of the pelvis, the membranes unruptured, 
and I allowed the moderate use of Duncan and Flockhart's 
chloroform during the pains, to an extent sufficient to deaden 
sensibihty without rendering her unconscious or unable to 
see what was going on in the room. The child was born at 
a quarter-past twelve, when I deepened the influence of the 
agent to insensibility, and allowed her to remain unconscious 
for not more than -Qxe minutes. The membranes ruptm-ed 
just before the birth of a living male child, weighing 11|- 
Ibs., when the ansesthetic was discontinued, and the patient 
immediately awakened without assistance, and the customary 
congratulations of the lying-in chamber were interchanged. 
With the child there came about a double handful of clots. 



YO OBSTETRIC CLINIC. 

and no furtlier hemorrhage occurred at any thne. The 
uterus contracted fii'mlj around the placenta, and after fol- 
lowing it down with my left hand, I sat by my patient's side 
to insure the maintenance of permanent uterine contraction 
with my hand, as is always my habit. The placenta was 
expelled from the vagina without assistance after a few 
moments, the membranes remained in utero, but soon came 
entirely away, after they had been twisted, and carefully 
manipulated, after which I remained quietly by the patient, 
grasping the uterus steadily, and watching its behayior. 
The contraction was so permanent, that I was about to apply 
the binder — the friends had been admiring the child, and 
the mother, joining in the conversation, had desired that the 
child should be brought to her, and had examined and 
caressed it, without raising her head from the pillow. In 
short, every thing was going on in the most natural manner, 
when, without any apparent reason, certainly without 
hemorrhage, the mother suddenly fainted, and the pulsa- 
tions of the radial artery became indistinguishable. Retain- 
ing my grasp of the uterus, I sprang on the bed, and raised 
the legs and pelvis high in the air with one hand, while 
maintainiug my grasp of the uterus with the other, ordering 
the while that the pillow should be taken from under her 
head, that the window should be opened, and that cold water 
should be dashed on her face. She rallied, but so imperfectly 
that I sent one bystander for medical aid, while another 
fed her with brandy, and a third went in search of aromatic 
spirits of ammonia and beef-tea. 

And now began a series of fainting-fits of the most alarm- 
ing character, with prostration like that of approaching death 
by syncope, soon aggravated by distressing nausea and vomit- 
ing. The surface became very cool, the features pinched, the 
complexion livid. Consciousness returned in the intervals of 
the fainting-fits, when she was calm, but complained of 
dreadful suffermgs from dyspnoea. I may say, once for all, 
that for nearly three hours I maintained, or caused to be 



CHLOEOFOEM, ETC., IN PrEEPEEAL ECLAMPSIA. 71 

maintained, continued grasp of tlie nteriis, tliongli it was all 
the while well contracted, nor did hemorrhage take place ; 
but I felt that the loss of a very trifling amount of blood 
wonld tm-n the scale. There was no evidence of uterine 
laceration ; the heart sounds, thongh very feeble and rapid, 
could both be heard, and there was no physical sign of dis- 
ease of that organ ; there seemed no other indications than to 
keep the blood in the head and trunk and support the strength. 
Thus in addition to brandy by the mouth, fresh air, sprink- 
lings, elevation of pelvis, legs, and arms, bottles of hot water 
held to the legs and feet, chloroform as a counter-irritant to 
the epigastrium ; I also controlled one femoral artery. In 
rather less than three-quarters of an hour, I had the gratifica- 
tion of seeing Professor Gilman enter the room, who fully 
recognized the very critical condition of my patient, and 
aided me most efficiently in the struggle for her life. When 
finally it was evident that nothing could be retained on the 
stomach, we gave brandy, and subsequently brandy and beef- 
tea by enemata, which were kept in by firm pressure against 
the anus. An horn' or two later Dr. Metcalfe came, by which 
time the fainting-fits no longer coincided with diminished 
volume of pulse. Her thirst was very great, but her stomach 
could retain nothing ; though after vomiting, her dyspnoea 
would be temporarily relieved. Stomach large and tympa- 
nitic. Pulse about one hundred and thirty, regular, but feeble. 
JS'itric acid and subsequently hydrocyanic acid were given, 
and after several stimulating applications to the epigastrium, 
a blister was applied. 

By evening w^e felt that the chief danger was over for our 
patient, who had previously calmly and without a murmur 
resigned herself to die, and the proposition of Dr. Gilman to 
add opium to the injections was adopted. I remained with 
her the entire night. The vomiting ceased about midnight, 
nor did it return, and she dozed somewhat. In addition to 
the brandy given by the mouth, I injected into the bowels 
ten and a half ounces of brandy in beef-tea, with a hundred 



7Z OBSTETEIC CLIKIC. 

and sixty drops of laiidauiim, as well as a grain of tlie watery 
extract of opium. 

Jime 14. — She lias made a slow and tedious convalescence, 
without, however, snifering from any other symptoms than 
profound debility and tendency to syncope. She nurses her 
child, and is now able to take a very fair amount of exercise, 
and has increased in weight. The treatment has been solely 
of a supporting and stimulating character. On one occasion 
shortly after her confinement I thought that I could detect a 
faint systolic basic murmur, but it did not reappear on the next 
examination, and I have been loath to fix her attention too 
much on her heart, which is certainly not hypertrophied. 
During the consultation neither Dr. Metcalfe, Dr. Gilman, 
nor myself could ascertain more than I have noted. 

In my memoranda at that time the following remarks oc- 
cur : The key to these phenomena may possibly be foimd in 
cardiac lesion ; they may possibly have been induced by the 
angesthetic, though I submit that a careful examination of 
the case does not in my opinion substantiate that theory; 
//while it is too well known that we have yet to seek the ex- 
planation of many cases of sudden death after labor i/and that 
in many no one could prognosticate lesions only discoverable 
by an autopsy. 

Subsequent History. — Four years later this unfortunate 
lady consulted me, on her return from a visit to a sulphur 
spring, for some irregular chills, and other symptoms which 
resembled former attacks of intermittent fever for which she 
had been treated. She was menstruating at the time, had 
been regular, and did not suppose herself to be enceinte. 
However, on the following morning she was suddenly de- 
livered of a three-months' foetus. Dr. Metcalfe being in the 
immediate neighborhood, was called, and delivered so much 
of the placenta as he could get away. Tiie day passed 
quietly, and on the following morning. Dr. Swift being 
present, I removed all of the remainder but a very small por- 
tion. It was soft, friable, and foetid. This portion was so at- 



CHLOEOFOKM, ETC., m PUEEPEEAL ECLAINIPSIA. id 

tacbed that I iiiiallj left it, tliinking that risk less dangerous 
tliau removal. Subsequently symptoms of pyaemia sboTVed 
themselves, the peculiar sweet breath first attracting my at- 
tention. Prof. Metcalfe saw her with me for some days, and 
then left town, with the conviction that she would do well. 
Prof. Thomas supplied his place, and shared the favorable 
opinion. At last, on one visit, he and I found a good pulse, 
perfect intelligence, freedom from pain on pressure any- 
where over the abdomen, or by conjoined manipulation, and, 
in short, such symptoms as made us both attribute my anx- 
iety to my personal relations to the patient. Within an 
hour after this visit a change occurred, and I saw that she 
must die, as, indeed, she did v/ithin a few hours, peacefully, 
free from pain, conscious to the last. 

The autopsy was made by Dr. Gouley, in the presence 
of Profs. Alonzo Clark and Thomas, and the following 
memoranda were written by the latter gentleman : 

" Post-mortem Examination of the Body of , 

September 8, 1865. — ^Examination fourteen hours after death. 
Weather warm; thermometer at 75°. Pigor mortis well 
marked. 

Upon abdominal section evidences of general peritonitis 
were discovered. The intestines were much distended by 
gas, and bound together by recently-effused lymph. The 
capillaries of the peritoneum were everywhere found in- 
jected, and the whole surface was bathed in pus. About 
three pints of sero-purulent fluid were removed from the 
cavity. On, or rather over the fundus uteri, an abscess hold- 
ing about two ounces of pus was found ; one wall formed 
by meso-colon, and the other by fundus uteri. This abscess 
extended down into the recto-vaginal cul de sac, and in it the 
fimbriated extremity of left Fallopian tube was immersed. 

The uterus, ovaries, and Fallopian tubes being removed, 
an examination of them revealed these facts : The abscess 
at the fundus uteri was due to acute inflammation of the left 
ovary, which had discharged itself into the space above men- 



Y4 OBSTETEIO CLIXIC. 

tioned. A piece of foetid placenta, about the size of a lialf 
dollar, was found attached to the left honi of the uterns. 
The nterine cavity was abont '^xe inches in length. 

Heart — a clot was found in left auricle ; the tissue was 
flabbv, and so soft that the finger could be readily "thrust 
through it at any point. To the naked eye it appeared 
fatty, and the microscopic examination by Dr. Gouley showed 
fatty degeneration. The mitral valves contained a consid- 
erable amount of atheroma. The spleen was hypertrophied, 
and its Malpighian bodies were very large. The kidneys 
were perfectly healthy. Xo other organs were examined." 

In this case the heart sounds were clear and very distinct, 
and the impulse perfectly marked to the day of the patient's 
death. Although the previous history had made us search 
most carefully for the evidences of disease of that organ, 
none could be recognized. It is my belief that the fatty 
degeneration existed at the time of the dangerous syncope, 
and was one of its factors. 

Case 25. — PoicerlesslcLbor ; delay j unexjpecUd change of 
foetal head ; forceps ; sul/phnric ether for cardiac murraur. 

!MJ's. , primipara, was confined September 19, 1S61. 

Dm-ation of labor, twenty-four hom-s. At the commence- 
ment of labor the head presented in the first position, a fact 
recognized by Prof. Barker and myself. The progress was 
slow and unsatisfactory, pains inefifectual, and not strength- 
ened by 3J. of Squibb's fl. ext. of ergot, and 3 yj. of Xeer- 
gaard's saturated tincture. After waiting twenty-fom- hours, 
Dr. Thomas was called in consultation, and I requested him 
to decide the question of interference. He advised the use 
of forceps, and recognized the posterior fontanelle just behind 
the right acetabuhmi, where indeed it was, having passed 
there dming the twelve hours or more which had elapsed 
since my examination of the position. As she had a systolic, 
mitral, cardiac murmm-, she was brought under the influence 



T5 

of etlier by Dr. Thomas, wlien I delivered Ler of a living 
female child with forceps. The parietal bones were remark- 
ablv thin and parchment-like, and the sutures quite wide. 
The placenta was so tightly grasped by irregular uterine 
contraction, that it had to be removed by the hand. The 
child had some hemorrhage from the vulva on the fourth 
day, after which it did well. Mother recovered perfectly. 
In the subsequent pregnancies of this patient, which have 
been numerous, she has always taken ether, and has done wxU. 

Case 26. — Forcejps for delay 'y amylene. BeUevue — 
Dr. J. G. Drajjer^ House Physician. 

Eliza Douglas ; aged 29 ; second confinement ; labor com- 
menced May 17, 185T, at 6 a. m., and was terminated on the 
18th, at 8 p. M. Position E. O. A. Before applying forceps, 
5 iij. of amelyne (all that I had with me) were given to the 
patient, without successfully inducing anaesthesia ; chloroform 
was then administered, and the patient promptly put to 
sleep, when I delivered a female child, weighing between 
seven and eight pounds. The child did well, I believe; 
mother recovered. This is the only case in which I have 
ever used amylene, its behavior in that instance not tempting 
me to experiment further. 

Yenesectio7i. — ^We are tempted to use venesection in cases 
of puerperal eclampsia by the recommendations of authors, 
and of so many practitioners — by clinical traditions in short — 
as well as by the appearances of great congestion observed 
in the head and face during the progress of the attacks. The 
purple, livid face and lips, and tongue ; the congested con- 
junctivae ; and the duskiness of the skin, which is often 
observed ; suggest abstraction of blood as a measure of relief. 
If we analyze our apprehensions, however, we find that 
extravasation of blood upon the brain is w^hat we chiefly 
dread ; and if we examine the records of autopsies we find 
that such a contingency is extremely infrequent, and probably 



Y6 OBSTETBIC CLIXIC. 

associated in tlie majority of cases with fatty degeneration 
of the blood-vessels of that organ. 

Kor can it be said that cerebral extravasations are infre- 
quent because of venesectionj for statistics show that we 
may assert the fact in cases where this treatment has been 
discarded. 

Moreover, it may safely be said that a majority of 
the severe cases of eclampsia occm- in patients who are 
ansemic, and whose subsequent histories display tendencies 
to hydrgemia, and that a roborant treatment with iron is 
most generally indicated after the immediate dangers of the 
confinement shall have passed. It is obvious that copious 
abstraction of blood, during the progress of these attacks, 
must therefore unfavorably influence the future convalescence 
of many of these patients. 

Another and natural argument for venesection at the pres- 
ent day, may be found in the likelihood that it may remove 
some of the poisonous principles which are supposed to affect 
the nervous centres ; but we may eliminate these by other 
channels, and meanwhile powerfully control their influence 
by chloroform, until we shall have terminated the labor. 

Still, in patients of a plethoric habit, and more especially 
in cases where we suspect that atheromatous degeneration 
may be present, the moderate abstraction of blood may be a 
judicious practice, and not liable to do harm. But large 
and repeated bleedings do not seem to me to be indicated. 
Where there are evidences of ansemia, the abstraction of 
blood should be resorted to with the greatest hesitation. 

In a great majority of my cases blood has been taken, 
though rarely by venesection, and in moderate quantities. 
In most wet cups have been used, a process applicable in 
various parts of the body, which adds the advantage of 
counter-irritation to the treatment, and measures accm-ately 
the amount of blood which is withdrawn, without the risk, 
so common in venesection, of taking more than is desired. 

I find myself resorting less frequently to this practice 



CHL0K0F0E3I, ETC., IX PUEEPEEAL ECLAMPSIA. il 

even, or Tritli less coiifideuce in the abstraction of blood in 
eacli succeeding year. In some cases it has seemed to me 
that the application of dry or wet cups over the kidneys has 
favorably influenced the action of diuretics. 

In the following case venesection seemed to act very 
favorably : 

Case 27. — Piierjyeral eclampsia * venesection. Bellevue 
Dr, Levi Warren^ House Physician. 

Margaret Maloney ; aged 17 ; primipara ; delicate-look- 
ing ; complained for two days of some pain in the head 
as well as in the right side and stomach. Some castor-oi] 
was given in the evening of October 11th, which had operated 
twice by 9 o'clock, when Dr. Warren was summoned, and 
found her breathing stertorously, with a pulse of 160, rather 
small, hard, and incompressible. Sinapisms to the feet were 
ordered, and an injection of assafoetida and turpentine. In 
five minutes a second convulsion came on, when she bit her 
tongue ; a cork was then introduced between her teeth. A 
third and fourth immediately succeeded each other, merging 
into a convulsive paroxysm which lasted forty minutes, and 
only yielded to chloroform. Os dilatable and about the size 
of a dime. Sclerotic conjunctivse, at first pale and healthy 
in appearance^ were now (10 p. m.) much congested ; pupils, 
before natural, were now contracted ; face flushed, livid, con- 
gested ; breathing stertorous and labored ; pulse 160, hard, 
small, and incompressible as before. Her head and shoulders 
being now somewhat elevated, she was bled from a good- 
sized orifice to about twenty ounces, when she showed signs 
of commencing syncope. 11-| p. m. — Pulse 130 ; respiration 
32, and quite easy. 12|- a. m. — ^Pulse 115, full, soft, and 
compressible ; pupils natural ; respiration natural ; some 
jactitation ; not altogether conscious. 

Octoler 12^A, 2 a. m. — Quite restless ; much jactitation ; 
pulse and respiration as before ; os dilated, to the size of a 



ib 0B5TETEIC CLIXIC. 

twentj-five cent piece ; labor-pains now commenced ; she 
recoYered from her stupor and became rational ; membranes 
ruptured at 3 a. m. ; head came to a K. O. A., and at a quarter- 
past four she was dehvered of a still-born child, weighing 
'Bxe pounds and a c[uarter. Placenta came away immedi- 
ately. Urine albuminous, but not markedly so. October 
XZtli^ 9 A. M. — Pulse 100, and quite feeble ; some vertigo. At 
noon pulse 112, and stronger : appears di'owsy and indifferent 
to what passes. From this time she continued to improve, 
requiring for some two or three days small doses of morphine 
with a little brandy, and on the 30th was discharged, well. 
This case happened some ten years ago, and was seen by 
Prof. McCready and myself. 

Case 28. — Puerjperal eclamjma ; forceps. 

Hannah Lane; aged 20; &st; L. O. A. In labor three 
hom-s. Still-born female child, seven and a quarter pounds. 
Dr. Chas. Phelps, House Surgeon, Bellevue. 

First seen by Dr. P. at 7 p. m. in a convulsion, which 
was rapidly followed by others with decreasing intervals of 
rest. In these intervals she was at first conscious, but soon 
became utterly insensible. Urine loaded ^vith albumen. Sp. 
grav. 1011. Olei tiglii crotonis gtt. j. I saw her at half- 
past nine, breathing oppressed, frequent, and stertorous, 
mouth covered with foam, tongue protruded, pupils con- 
tracted. Conjunctivas suffused, face persistently livid, hps 
markedly so, tongue very dark. Pulse 148, laboring and 
very hard. Uterus dilated to the size of half a dollar, thin, 
somewhat rigid and undilatable. llembranes ruptured, 
though much liquor amnii remained. Head in fii'st position 
— foetal heart inaudible. "Wliile observing these facts, another 
convulsion of a very violent epileptiform character occurred, 
ushered in by pleurosthotonos. Both arms of the patient 
bore traces of previous venesection. Under these circum- 
stances. Dr. Taylor (who had arrived) concurred in recom- 



CHLOEOrOKM, ETC., IN PUEEPEEAL ECLAIMPSIA. 79 

mending venesection, and Dr. Plielps took about 3 xx pleno 
rivo from the arm; after this the pupils dilated, lips and 
tongue became much paler, but the pulse very feeble. She 
was then carried carefully into the lying-in ward with her head 
down. Pains continued strong, and in about three-quarters 
of an hour the os had dilated sufficiently to admit the forceps, 
and I delivered her with forceps of a still-born child. 'No con- 
vulsions after delivery, but the patient remained in a semi- 
comatose and very restless condition till 5 a. m., when she died. 
Memorandum of autopsy not preserved. 

Case 29. — Puerjperal eclampsia ; forceps. — Drs. George 
S. Hardaway^ House Physician^ and Henry F, Andrews., 
Senior Assistant. 

Catharine Murphy, aged 18, unmarried, primipara, fell in 
labor at Bellevue Hospital at 4.30 a. m., January 16, 1858. 
Pains strong till hall past seven, when she was seized with a 
strong convulsion. Muscles strongly contracted ; face deeply 
congested ; teeth clinched ; foamed at the mouth, but did not 
bite her tongue. After the convulsion the respiration was 
stertorous, and the face remained congested for some time, 
pupils acting sluggishly. After this the pains were less fre- 
quent, and feeble. Urine drawn off with a catheter, and found 
to be slightly albuminous. 9 a. m. — Convulsion, similar in 
character and consequences. Os fully dilated. Ant. fonta- 
nelle down in a line a little in advance of right eminentia-ileo- 
pectinea. Posterior fontanelle a little in advance of right sacro- 
il.-syn. Foetal heart most distinct at junction of supra-pubic 
and right iliac regions. Dr. Elliot ruptured the membranes 
at 11 A.M. Pulse 92.1 p.m. — Tr. Ergots 3J. li p. m. — 
Another strong convalsion, during the stertorous stage of 
which Dr. Elliot applied his forceps with the pivot, and de- 
livered without delay. No mark was left on the child, al- 
though one blade was applied over the face, and one over 
the occiput, rotation not having fully taken place. Perineum 



80 OBSTETEIC CLDsIC. 

somewliat lacerated. After deliver}^, lijd. cLlor. mit. 3 ss 
in butter on back of tongue, and in two hom's ol. ric. 3 j 
Half stupid till 4 p. m., when she had another convulsion, 
leaving her face deeply congested. Pulse 90, full and labor- 
ing. Put in a sitting posture and bled to 5 xvj. Pulse be- 
came now less frequent and softer. 'No signs of syncope. 
Medicine operated freely at 5-J p. m. Pemoved to a quiet 
room, and ice applied to her head. 7 p. m. — ^Pational and 
easy ; pulse 104, soft. 7.35. — 96. 9 p. m. — Another convul- 
sion ; 4 c.c. to nape of neck. Slept quietly all night. 17th. 
— ^Pulse 84-88. Condition good. Child well, weighing six 
pounds. Both made a good recovery. 

A sample of blood was carefully examined by Prof. Do- 
remus, and found to contain no urea. Microscope disclosed 
granular reual epithelium, waxy casts, and blood corpuscles. 

Case 30. — Fuerjjyeral eclampsia / urine free from al- 
hum en y . forceps. 

Mrs. , primi^Dara, aged 22, fell in labor in the 

evening of November- 19, 1861. She had previously con- 
sulted me regarding her prospects, and I had made two ex- 
aminations of the urine, which gave me a good specific grav- 
ity and no albumen. No microscopic examination made. 
She was robust, well-built, healthy. Expression of face good, 
no puffiness. Some oedema of feet. Fingers somewhat swol- 
len, rings removed. Bowels had been freely moved. I ex- 
amined her on the 20th, and found the pelvis normal, os 
slightly open, soft parts not much relaxed, well-ossified head 
presenting in the first position. Foetal heart to the left side. 
Uterine souffle distinct over the umbilical and hypogastric 
regions. The pains continued dming the day and night 
with moderate efi'ect, dilatation of os steadily progressing, 
and its dilatability well marked. 21st, 9 a. m. — The mem- 
branes had now reached the floor of the pelvis, when they 
broke. At noon gave tr. ergotse 3 ss., as but little advance 



)., IX PUEEPEEAL ECLAMPSIA. 81 

was making. At lialf-past two the pains were better, wlieii 
suddenly she endeavored to raise herself in bed, turned par- 
tially to the right, and presented the well-marked phenome- 
non of an epileptiform convulsion, biting her tongue. Gave 
chloroform immediately, and sent for a consultation. Dr. 
Thomas and Professor Gilman arrived, when Dr. Thomas took 
charge of the chloroform, and 1 delivered a living male child, 
weighing nine pounds, with the forceps. The frontal bone 
was depressed nearly half an inch below the parietal. The 
uterus contracted fairly, retaining the placenta entirely with- 
in it, and as the cord seemed very full of blood, it was cut 
just above the ligatm'e, when a larger amount ran from it 
than any of the consultation remembered to have seen be- 
fore, amounting, according to our estimate, to between four 
and Rye ounces. Drs. Thomas and Gilman now left, and I 
continued the influence of the chloroform. Some twenty min- 
utes afterward the placenta had not passed into the vagina, 
and the fundus uteri relaxed in a curious way without en- 
largement, giving to the hand the sensation of an extremely 
thin uterine wall, so I made a more careful examination, and 
found the circular fibres tightly constricted, and the placenta 
retained as though in a bag with the mouth drawn. Deep- 
ening the chloroform, and dilating the cervix, I removed the 
placenta from the fundus, and after a good dose of ergot per- 
manent contraction ensued. When the binder was on, the 
chloroform was discontinued, and consciousness returned, 
but the capillary congestion of the face, which was very 
marked, had not subsided, as it so generally does under chlo- 
roform. Pulse rather rapid and very feeble. Sent for Dr. 
Eoss to apply wet cups to both temples, and had some 3 v. 
of blood taken. When the cups were first applied a violent 
convulsion followed, and this was the last. Tongue saved 
from being bitten. 

26th. — Has done well. Bowels free, lochia good, milk 
secreted. Urine normal in amount, any little excitement 
controlled and anticipated by morphia. Decemher 1st. — 
6 



82 OBSTETRIC CLIKIC. 

Has suffered intensely for three days from periodic head- 
ache, best marked a little after noon. Quin. sulphatis gr. 
X. 2d. — Ears ring, headache relieved. Continue moderate 
prophylactic doses. February lOth^ 1862. — Has done well, 
nurses her child. The protracted lochia have ceased. Uterus 
normal. Urine examined by Dr. W. H. Draper. Specific 
gravity 1009, not albuminous. IN'othing under microscope 
but vesical epithelium. Has since continued well. 

Case 31. — Puerperal eclampsia; venesection; cups; 
chloroform, — Dr. Samuel Forman^ House Surgeon. 

Mary Connors ; Irish ; domestic ; aged 21 ; married ; 
primipara ; a large, stout, plethoric woman ; admitted to 
Bellevue February 1, 1858. l!^o history of previous disease. 
Troubled with vomiting and headache during pregnancy. 
Entered lying-in ward in the night of February 14:th, in 
1 abor. Her pains were strong, and at midnight she fancied 
that she saw men standing about her. February X'^th^ 4 A. m. 
— Pains still strong ; complained that she could not see. 5 a. 
M. — First convulsion, followed by another in an hour. ISTot very 
violent. Os dilating; head presenting L. O. A. Another 
convulsion at 8 and another at 9, when she was seen by Dr. 
Elliot, and bled i viij. from the arm. Pulse fell to 80. Som- 
nolent. Urine drawn with catheter, highly albuminous ; os 
dilating ; head advancing ; foetal heart beating in the left 
iliac region. Fifteen minutes after venesection a convulsion. 
Chloroform. Pulse 80. Pupils very much contracted. De- 
livered at 10.15. Woman unconscious at the time. Child 
feeble. 10.30.— Convulsion. Pulse 91. Ordered by Dr. 
Elliot ten grains of calomel mixed with butter, and 5 j castor- 
oil four hours after. C.C., N'o. iv., over each kidney. Con- 
vulsions to be anticipated if possible by chloroform. At 11 
grinding teeth ; restless. Chloroform. Soon became quiet, 
and then conscious. 12.45. — Slight convulsion. Pestlessness 
increasing. Chloroform. 1 p. m. — C.C. 2.15. — Tliree con- 
vulsions have been warded off by chloroform. Awoke now. 



:■., IN PUEEPERAL ECLMIPSIA. 83 

Said she felt cold, and was immediately convulsed, the seizure 
lasting about sixty seconds. 2.50. — Slight spasmodic move- 
ments. Pupils dilating during spasm, and then contracting. 
Chloroform. 3.10. — Restless. Chloroform till quiet. 3.53. — 
After some restlessness awoke, and immediately became con- 
vulsed. Lasted about twenty seconds. Chloroform. Strong 
stertorous breathing. Pulse 90 ; rather soft. 4.27. — Three 
times convulsions have threatened, and been warded off 
by chloroform. Some twitching of the eyelids being no- 
ticed, chloroform was given, but before she came under 
its influence sufficiently the spasm came on. Pupils di- 
lated. Pulse 116. 4.40. — Another slight one. Chloro- 
form freely. 5.20. — A very slight convulsion. "No pre- 
monitory symptoms. Pulse 96. Pupils contracted after 
spasm. 6.50. — Three more restless attacks have been con- 
trolled by chloroform. Eestless again. Chloroform. Con- 
vulsion lasting sixty seconds. 7 p. m. — Another lasting forty 
seconds. Afterward pulse 110. 7.20. — A violent convulsion, 
lasting ninety seconds. Afterward pulse 160. Soon after 
another less violent, and then pulse irregular and intermit- 
tent. Eespiration 26. Chloroform. 9 p. m. — Three restless 
attacks controlled by chloroform. 

Yisited by Drs. Elliot and Taylor ; decided not to bleed ; 
pulse counter-indicating ; advised C.C. to back of neck, and 
chloroform continued. 9.30 p. m. — Bowels moved freely after 
injection ; C.C, 'No. iv., to back of neck ; pulse 126, feeble ; 
respiration 24 ; chloroform ; quiet until 11.15 ; awoke, and 
had a violent convulsion, lasting a minute and a half; pulse 
after it 165. 11.30. — Restless; chloroform again; bowels 
moved again. JFebruary 16th, 2.30 a. m. — Has had no con- 
vulsion since 11.15 ; chloroform continued ; pulse 100, feeble. 
Y.05. — Restless ; chloroform till quiet. 7.20. — Restless ; soon 
became quiet, sleeping ; continued to sleep until 9.45, when 
awoke, became restless; chloroform again. 10.30. — ^Pulse 
108 ; still quiet ; at 11 restless ; gave chloroform. 12 m. 
Awoke conscious for first time since first convulsion ; put 



84 OBSTETEIC CLIXIC. 

under chloroform again ; nrine drawn ; not so liiglilj albu- 
minous ; bowels again opened. 12.30. — Asked for drink, 
went to sleep again ; pulse 92, not so feeble ; respiration 21. 
4.30. — Pulse 120 ; respiration 18, asleep ; lias taken some 
nourishment; complains of headache. 7 p. m. — Eestless; 
complaining that her sides feel sore ; is conscious, answers 
questions readily ; has no headache ; beef-tea. February 
11th, 2.30 A. M.— Pulse 108 ; awake. 3.30.— Passed urine 
in large quantity ; sleeps nearly all the time. 10.30. — Awake ; 
sensible ; headache ; lochia profuse ; feels tired. February 
V^th, 9 A. M. — Pulse 100 ; sensible ; complains that her head 
feels heavy ; wants to eat. February l^th. — Urine drawn 
and tested ; albumen much diminished in quantity ; feels 
well ; no pain ; pulse feeble, not frequent. February 20th. 
Urine highly albuminous, becoming almost solid by heat and 
nitric acid ; under microscope no abnormal appearance ; 
urates abundant. February 21st. — Urine not so highly 
albuminous; epithelial cells of kidney looked unhealthy; 
no nuclei seen ; appeared slightly fatty. February 22d. 
Still less albumen; pus-cells, from lochial discharge. Feb- 
ruary 2Qth. — Yery little albumen ; abundance of urates. 
March 2d. — But a slight trace of albumen ; imder micro- 
scope abundance of pus-cells ; no epithelial cells found. 

Case 32. — Puerjperal eclam])da ; venesection', cathartics ; 
foTcejps. 

Catharine Walsh, aged 30 ; primipara ; entered the Lying- 
in Asylum October 24, 1852. I first saw her at 1 p. m. Up 
to this time she had been washing, and now had to lie down 
as her pains had commenced. The os was very high up and 
just sufficiently dilated to admit my finger. I noticed noth- 
ing unusual, and left the house for two hours. On my re- 
turn I found her comatose, and learned that she had sufi'ered 
three convulsions. Is'o treatment had been used except cold 
to the head. Her singularly robust, plethoric temperament, 
her full hard pulse, and the progressively increasing character 



CHLOEOFOEM, ETC., EN PUERPEEAL ECLAMPSIA. 85 

of the convulsions, determined me to bleed lier. I took 3 xij 
of blood, Trhen consciousness returned. Ordered an enema 
of soft soap and tlie sulphate of magnesia ; ice to the head ; 
feet and legs to be kept warm. Consciousness had returned 
between the former attacks. In reply to her earnest ques- 
tioning, I informed her that she Jiad fainted — nothing more. 
I then noticed oedema of the legs, and found the urine loaded 
with albumen ; no foetal heart audible ; os uteri half dilated 
and high np. I also sent for Dr. Thomas F. Cock, one of 
the physicians of the asylum. At six she had a fourth con- 
vulsion, when I dashed two basins of water in her face with- 
out benefit, and then reopening the vein took |xij more. 
Dr. Cock, then arriving, directed the administration of ten 
grains of calomel in butter, and some sweet spirits of nitre, 
but declined to allow the exhibition of chloroform, except 
during the convulsions. It was decided to use forceps when 
practicable. At eight she had a fifth convulsion, when I 
gave chloroform. At 9 p. m. Dr. Cook returned with Dr. 
Beadle, when the head being well within reach, I delivered 
her with forceps of a still-born male child. At 1 A. m. she 
had a slight convulsion, which was the last. 

October 22, 1852. — ^Bowels moved by the calomel ; doing 
well ; pain on pressure over the kidneys ; cupped over the 
lumbar regions to 3 xij. The urine drawn off yesterday with 
the catheter displays casts of the nriniferous tubes under 
the microscope. From this time till she left the house 
she steadily improved; oedema gradually disappeared, and 
though there would occasionally be albumen in the urine, it 
was slight in quantity, and could not be depended on as a 
daily secretion. Her treatment has consisted in the steady 
employment of saline cathartics. 

Case 33. — Convulsions ; aTbuminuria j forceps. — Dr. E. 
W. Lambert^ House Physician. 

A. McKay, unmarried primipara, in Bellevue, aged 19. 
Labor-pains commencing at T p. m., August 2d. Waters 



86 OBSTETEIO CLINIC. 

broke wliile asleep at 9 p. m. Head preseuting ; os the size 
of a dollar, and very dilatable. Second fit at 10 p. m. ; third 
in twenty minntes. Chloroform now, and Dr. Elliot sent 
for, and came immediately with Dr. William T. Green Morton, 
of Boston, who happened to be with him ; aj)plied the forceps, 
placing the pivot in the second hole, and delivered a living 
child without any laceration of perineum, although the vulva 
was very narrow. Placenta gave no trouble. Chloroform 
kept up for about twenty-four hours. Whenever the patient 
came from under its influence a convnlsion would occur. 
Urine drawn with catheter, highly albuminous, though there 
was no trace of oedema, no congestion of face after convul- 
sion. Specific gravity 1018 ; no blood ; c.c. 'No, v. to kid- 
neys ; emp. vesic. to nape of neck. No attack of convulsion 
after midnight of the 3d. Yomited a great deal subse- 
quently, relieved by the dilute hydrocyanic acid. August 
Sth. — ^Doing well. 

Remarks. — In this case the forceps were introduced en- 
tu'ely within the os uteri, which readily dilated before the 
tractions with the instrument. 

Case 31. — Puerperal eclampsia; chl(yroform ; cups; 
forceps. 

Emily Gray, an unmarried Irish woman, thirty years 
of age, was driven from her home in the seventh month of 
her first pregnancy, and came to this country without friends 
or money. 

She had resorted to very tight lacing as a means of con- 
cealing her pregnancy, and I had in my possession the iron 
corset-bone which she used to assist her. This, it will be re- 
membered, is one of the causes assigned by Dr. Cormack for 
albuminuria in pregnancy. 

Novemler 21, 1852. — Her labor commenced under the 
care of Mr. Peck, of Ohio, and Mr. Walker and Dr. Meizner, 
of Kentucky— the first two being students of medicine. 



CHLOEOFOEM, ETC., ET PDEEPEEAL ECLAMPSIA. 87 

At IJ A. M. the OS was fully dilated and the membranes rup- 
tured ; and at 2 a. m. she was in convulsions. Between the 
third and foui*th, chloroform was exhibited bj Dr. M., and I 
arrived at the house at the termination of the fourth. E"o 
other ti'eatment had been resorted to. I found the pulse 
frequent, feeble, and compressible; utter unconsciousness, 
with stertorous respiration ; eyes partially open, pupils some- 
what dilated ; no oedema of the feet or legs, or marked puffi- 
ness of the face; bladder somewhat distended, and when 
relieved by the catheter, nitric acid showed the urine to be 
loaded with albumen ; parts well dilated ; head presenting 
in the first position, and well down; pains moderate, and 
foetal heart inaudible. At the commencement of the fifth 
convulsion chloroform was exhibited, and its use continued 
until I had extracted a dead child with the forceps, removed 
the after-birth, and applied the binder. The uterus re- 
mained well contracted, and she had no other convulsions ; 
her pulse was feeble, but rallied, and she was ordered an in- 
jection of soft soap and salt ; gr. xij of calomel were given in 
butter, and Granville's lotion applied to the nape of the 
neck. Consciousness returned in about two hours. 

1 p. ]M. — Foimd her complaining of fixed pain in the top 
of her head, and some reaction commencing ; bladder re- 
lieved by the catheter ; 3 ij of blood were taken by cups 
from the temples ; cream of tartar as a drink, with 3 ij of 
sweet spirits of nitre during the day; feet and legs kept 
warm ; absolute rest enjoined. In the evening she was rest- 
less, and the gentlemen gave her a full anodyne. 

Novefiriber 2^ih^ 1 p. m. — Much improved ; pain in head 
gone ; pulse good ; mind anxious and desponding ; complains 
greatly of her tongue, which was severely bitten ; decided 
pain on pressure over her kidneys. Ordered to gargle her 
mouth with a weak solution of the chlorinate of soda ; saline 
drinks to be continued ; bowels to be moved with an injec- 
tion ; and cups to be applied over the lumbar region. 

Novemler SOth, 1 p. m. — I found her extended o?i tlieflooi\ 



88 OBSTETEIC CLIXIC. 

apj)arentlj dead ; I revived her and lifted her into bed, when 
I learned that, desiring to have a motion, she had arisen 
three times, and that on sncceeding she had fainted. I im- 
pressed on her, and the kind old woman who had afforded 
her a shelter in her solitary little room, that snch another 
imprudence would be probably fatal ; and as the pulse was 
returning to its usual state, I left, after requesting that the 
catheter might be passed, as the bladder had not been 
emptied since the night before. She objected to its use: 
and the gentlemen left, promising to return. 'WTien they 
did so, the nurse pronounced her asleep, and they found her 
dead. She had been again in the upright position, and had 
had some of her linen changed, just after which she had sunk 
on the bed, asleep as the old nurse thought. I would espe- 
cially mention, that she had passed a very comfortable night, 
and had expressed herself as much better on the morning of 
her death. Xo more than 3 vj of blood had been taken by 
the cups. 

Autopsy. — Twenty hours after death, by my friend. Dr. 
C. E. Isaacs. Brain firm and healthy, but remarkably pale 
— even the choroid plexus being of a much lighter color than 
natm-al ; all the other organs healthy, excepting the kidneys, 
which were found to be enlarged and congested, but not 
changed in structure ; the corpus luteum was beautifully 
marked ; the urine which I drew off with the catheter before 
delivery was examined by Professor Clark, and found to 
contain blood-corpuscles, but no casts or fat-globules. 

I may mention that although her feet and legs were not 
swollen when I was called to her, she had complained of very 
great inconvenience from that cause up to within a short 
time of her confinement. 

I believe that she died from syncope, resulting from her 
efforts to give the least possible trouble to the old woman 
who sheltered her, and on whom she felt herself entirely 
without claim. Perhaj)s it would have been better to have 
refrained in the case from the abstraction of any blood. 



ETC., liT PUERPERAL ECLAMPSIA. 89 

Case 35. — Puerj)eral eclampsia j chloroform; cups. 

Mary Brady, an asylum patient, was in labor with her 
third child at 1 a. m., December 4, 1852. She had been 
troubled during the night with sparks and white spots flash- 
ing before her eyes, and suffered more than is usual from 
sickness at the stomach at the commencement of labor. I 
was called to her at 6 a. m. in consequence of her yery weak 
state, and found a divided opinion among the women sleep- 
ing in the ward, whether she had had a conyulsion some 
time before, or had only fainted, there haying been no light 
in the ward at that time. I found her quite conscious, yery 
pale, moaning and complaining of great pain in the head ; 
pulse yery feeble and compressible ; extremities quite cold ; 
OS uteri dilated to the size of a dollar, and dilatable ; with 
the parts well relaxed and the pelyis roomy, and labor-pains 
slight; head presenting in the second position, membranes 
um^uptured ; pulsation of foetal heart yery distinct ; bladder 
empty; no oedema anywhere. Stimulus appeared to me to 
be indicated, and I bm^ned some brandy, which was grateful 
to her, and took my seat by her side with a guarded table- 
spoon ready. At 7 she had a conyulsion. She partially 
raised herself in bed, with her eyes staring and pupils dilated, 
mouth wide open, and head thrown back; her body then 
became rigid, eyelids tighly shut, mouth closed as far as I 
permitted, and tongue protruded. The characteristic, con- 
yulsiye, hissing, expiratory sound was heard for some mo- 
ments, when stertorous breathing was established, and the 
conyulsion ceased. In a short time consciousness returned ; 
her pulse remained feeble, and the foetal heart audible, 
though much weakened, with the labor-pains unimproyed : 
pain in head gone. Applied camphorated lotions to the 
head, and ordered a strong, stimulating injection, which yery 
markedly increased the uterine contractions, and tlie labor 
rapidly progressed. At 8 the pain in the head returned, and 
there was only time to introduce the spoon-handle when she 



90 OBSTETEIC CLIXIC. 

had aiiotlier convulsion similar to the one wliicli I have 
described. As soon as possible, I exhibited chloroform, and 
kept np its influence. Labor progressed, and I ruptured the 
membranes. At half-past 9 the child was born, in the 
presence of Dr. Metcalfe, one of the physicians of the Asy- 
lum, for whom I had sent about an hour before. The cord 
was wi-apped several times around the neck and once around 
the waist, and though pulsating feebly, the child was alive 
and did well. The placenta came readily away, and when 
the binder was applied she was allowed to revive, having 
been utterly unconscious since the administration of the 
ansesthetic. At 3 p. m. she had another convulsion, preceded 
by much after-pain, and this was the last. Urine di-awn off 
with the catheter was very albuminous, and contained casts 
of the uriniferous tubes, with blood and oil-globules, l^o 
oedema of the feet or legs, nor puffiness of the face. 

December 10th. — Up to this time, though feeble, she has 
done well. Urine still albuminous, but the quantity dimin- 
ishing; seized to-day with violent headache, resisting cold 
lotions and enemata ; cupped on the nape of the neck to s iv 
with immediate relief. After this she continued to improve, 
nursed the child, and left at the usual time — expiration of a 
month — still with a very appreciable amount of albumen in 
her urine, though some days it would be entii*ely absent. 

Case 36. — Confinement/ twins j 'puerperal eclampsia/ 
chloroform/ jpurgatives / cups. — Dr, TU. TF. Johnston^ 
House Physician. 

Elizabeth Fox, aged 23, born in Ireland, and unmarried, 
was admitted into Bellevue Hospital on the 4th day of 
May, 1866, in the ninth month of her first pregnancy, and 
stated that she had been in perfect health up to the time of 
her admission. 

May Uh. — She complained to-day of her legs being 
swollen, and on examination it was found that her lower 



CHLOEOFOEM, ETC., IX PUEEPEEAL ECLAMPSIA. 91 

limbs and abdominal walls were markedly anasarcoiis. A 
pm-gative was ordered with powders of the bitartrate of 
potassa, 3 i three times a day. On examining her nrine, a 
slight trace of albumen was discovered, but no casts were 
found under the microscope by Drs. Johnston and Gamble. 

May ^th. — She complains this morning of not passing her 
water freely. The bowels have been moved once. Ordered 
pnlv. pnrgans in such doses as to keep the discharges watery. 
Bitart. potass, continued. 

Dr. Elliot saw her to-day, and advised wet cups to be 
applied over the lumbar region, hot-air bath, and no meat. 

May Sth. — The hot-air bath had a very good effect, and 
produced a copious perspiration. The cups were not applied 
until to-day. 3 viij of blood were taken from over the kid- 
neys. The bowels were freely moved during the night, and 
her m-ine is somewhat increased in quantity. The oedema 
does not, however, seem to have diminished, but rather to 
be increased since treatment was commenced. 

May dth, 11 a. m. — She complained of pain in abdomen. 
Under the impression that she was about to be confined, she 
was transferred to the lying-in ward. 

May 9th, 1 p. m. — Dilatation of os commenced ; it pro- 
gressed very slowly, and in eleven hours the waters broke, 
and the head was found presenting in the first position. The 
child was born May 10th, at 2.15 a. m. Cord very short. A 
second bag of waters was then found presenting at the supe- 
rior strait, which was ruptured, and a second child promptly 
delivered by the breech. Two placentae. Third stage rapid. 
Both children born living ; the first, a boy, weighed 6J 
pounds ; the second, a girl, weighed 5 J. Slight hemorrhage 
followed the delivery of the placentsej which soon ceased, 
and the uterus contracted well. 

May 10th, 3 J- a. m. — ^Well-marked epileptiform convulsion, 
with spasmodic contraction of all the muscles, and frothing 
at the mouth. As soon as this had passed off she became 
perfectly sensible of what was going on, and complained of 



92 OBSTETEIC CLIXIC. 

lieaclaclie. Ice-bag to tlie head. 5 a. m. — A second. T a. m. 
— A tliii'd, after wliicli she remained insensible. 8. — Convul- 
sion. 8.20. — Do. 9.10. — Do. Enema given, followed bj 
a copious movement. Sleeps in tlie intervals of the attacks. 
Respiration stertorous. Xow and then restless, and throws 
herself about. Passes water involuntarilv. 

J^aij lOtJi, 10 A. [^.—Convulsion. 11.25.— Do. 12.— Do. 
12.30.— Do. 12.15.— Do. 1.15 p. ^.— Do. Pupils contracted. 
Pulse has ranged at 150. Xow and then seems sensible of 
pain. TTater now drawn. Pulse 161. Cups to the temples. 
About fiij of blood removed. 2.20. — Pespii'ation easier. 
Pupils more dilated. The endeavor has been made to con- 
trol the convulsions bv giving chloroform at the commence- 
ment of each. 2.30. — Convulsion. Hyd. chlor. mit. gr. x., 
pulv. jalapte gr. x., given in butter on the back of the tongue. 
3.10. — Hot-air bath, which produced profuse sweating. 3.25. 
— Some approach to consciousness. Is very restless. 3.50. — 
Two convulsions immediately succeeding each other. First 
veiy severe. 1.30. — Convulsion. Great restlessness. Chlo- 
roform. 5. — Face very much congested. Cups to back of 
neck ; 3 ij taken. Is more quiet than she has been for some 
time. ChlorofoiTQ continued when convulsions thi-eaten. 
Pulse 160. 5.50. — Convulsion ; long in dm'ation. Tine, of 
aconite. 6.30. — Does not remain quiet, lloans, and grits 
her teeth. 8. — Convulsion. 8.10. — Do. Yery restless. 
Pulse 162. Pespiration stertorous. Pupils dilated. Urine 
drawn. 9. — Convulsion. 9.30. — Do. Beef-tea has been 
given now and then. Swallows with difficulty. Blister to 
back of neck. 10.15. — Two convulsions ; one immediately 
after the other. 

May 10th, 10.15 p. at. — Has had two large passages from 
her bowels. 11.30. — From tliis time chloroform was admin- 
istered at such times and in such proportions as to keep her 
imder the influence of it all the time. 12.20. — Two convul- 
sions ; interval of ten minutes between them. 

JjTaT/ 11th, 1 A. M. — Is perfectly quiet under chloroform, 



CHLOEOFOEM, ETC., EN" PUEEPEEAL ECLAMPSIA. 'Jo 

and had another passage from bowels. 1.30 a. m. — E'o con- 
Tiilsion as yet. 4 a. m. — ^Water draTm, 3 iij. 6 a. m. — Con- 
vnlsion. Chloroform for an honr had not been given as 
persistently as before. 7 a. m. — ^Pulse 142. General snrface 
warm. Pupils contracted. 9 a. m. — ^Water drawn, iiv. 
Pnlse 140, and full. 11 a. m. — Has passed iirine involunta- 
rily. Iso conynlsion. Periods of excitement lasting a few 
moments, followed by insensibility and qniet. Pulse 150. 
11.30 A. M. — Pulse 138. Eespiration 40. There seems to 
be an effort at return of consciousness. Pupils respond to 
light. Jalap gr. x., podophyllin gr. i. 1 p. m. — Pulse 160. 
Eespiration 46. Spoke for the first time since May 10th at 
4 o'clock. Bowels opened twice. Circulation in hands and 
lips yery feeble. Mucus accumulates in larynx and impedes 
respiration. Endeavored to clear throat with probang. Par- 
tially successful. 3 p. m. — Eespiration difficult. Lips blue. 
Fingers cold. Urine drawn, sviij. Eespiration became more 
and more feeble, and she died at 3.10 p. m. 

Autojjsy. — Thirty hours after death. Brain healthy. 
Slight amount of sub-arachnoid effusion. Lungs emphysema- 
tous ; otherwise healthy. Heart slightly hypertrophied ; 
weight 3 xiij . ; under the microscope somewhat fatty, but 
degeneration not great. Liver weighed 4 lbs. 1 ij. ; cells 
filled with small granules of fat, but with no large globules 
in the cells, or free in the field. Uterus healthy. Kidneys 
large, white, very m.uch congested ; stellated appearance of 
surface; weighed together ixiij. 

MicrosGOjjic Examination hy Prof. A. Flinty Jr. — Cor- 
tical substance pale and granular, with red spots, apparently 
congested. The whitish portion was found to consist of tubes 
fiUed with dark granular matter, without a single perfect or 
even distinct cell. The granular matter filled the field. It 
was rendered pale by acetic acid. The Malpighian bodies 
were likewise filled with granular matter, so that the convo- 
luted blood-vessels could not be distinguished. In the 
congested portions the same condition of the tubes and Mai- 



94: OBSTETRIC CLDaC. 

pigliiau bodies was noted, and nmnerons imperfect crystals 
and grannies of liematoidin were discovered. In the pyra- 
midal snbstance tlie straight tubes were a httle more natnral 
in appearance than in the cortical, bnt even the cells were 
granular and indistinct. 

Case 37. — Puer])eral eclamjpsia ; mania. — Dr. Henry C. 
Eno, House Physician^ Reporter. 

Mary Langdon ; aged 15 ; well developed ; born in Eng- 
land ; entered Bellevne Hospital May 13, 1865, to await her 
confinement. She represented herself as having been raped 
. by two men in the street, and came to the hospital by the 
advice of some of her friends, bnt without the laiowledge of 
her father, who was ignorant of her misfortune. Her mine 
was examined both chemically and microscopically several 
times before her confinement, and nothing abnormal observed. 
On June Tth, at 9.51: A. m., she was delivered of a male child, 
weighing 8|- pounds. The labor was easy, and the mother 
seemed doing perfectly well until 4.45 p. :^., when she had a 
convulsion lasting ^nq minutes. Sufficient chloroform was ad- 
ministered to control the convulsive movements. The catheter 
was immediately passed, and albumen detected in the mine, 
which was acid, and had a specific gravity of 1007. The 
patient's bowels had been freely moved every day for three 
weeks before confinement ; also upon the morning of that 
day. She was put into the hot-air bath, ice was applied to 
the head, and mustard over the kidneys. At 5.35 p. m. she 
had another convulsion, lasting three minutes. Chloroform 
was again adminibtered. This convulsion, hke the previous 
one, was marked by convulsive movements of the whole body, 
frothing at the mouth, and biting of the tongue, and was fol- 
lowed by a period in which the mind was didl and confused, 
and in which the patient complained of headache. At five 
difl:erent times during the evening the patient had involun- 
tary startings, with grinning, and rolling of the eyes ; but 



CHLOEOFOEM, ETC., IN PUEKPEEAL ECLAMPSIA. 95 

upon tlie sparing administration of chloroform these were 
controlled, and no more regnlar convulsions followed. At 
8.15 p. M. the hot-air hath was removed, the patient having 
persjDired profusely, her mind being clearer, and the headache 
gone. Pulv. Doveri gr. v. were also given by Dr. I. E. Taylor's 
direction, and the dose repeated at 9.45 p. m. At 11.15 the 
patient was sleeping, and continued so until morning. 

June Sth. — Patient quite comfortable. Mind clear. 'No 
headache, but considerable thirst. At 9.30 a. m. gave ol. 
ricini 3 i. by Dr. Elliot's direction. Bowels moved freely in 
the evening. Slept much during the day, and a good deal 
of the night. 

Jime 9th. — ^Patient continues to feel well. Her urine, of 
which she passed four pints during the twenty-four hours, is 
acid, specific gravity 1014, and contains much less albumen 
than previously ; by the microscope nothing abnormal was 
discovered yesterday or to-day. Her bowels were opened by, 
a small dose of the sulphate of magnesia. In order to pre- 
vent the secretion of milk, cloths soaked in spirits of camphor 
were applied to the breasts. 

Jvme 10th. — Patient seems quite well during the day. 
Her urine the same as yesterday. In the evening com- 
plained of pains in the abdomen, like after-pains. Quite 
uneasy and hysterical, but quieted by hyoscyamus and cam- 
phor, and slept. 

June nth. — More albumen in the urine, and specific 
gravity 1019. Dr. ElHot prescribed a drachm of the tincture 
of ergot, to control the after-pains, as well as to facilitate the 
passage of urine, which heretofore has been drawn by the 
catheter ; also extract of belladonna in glycerine, to be ap- 
plied^ to the breasts, which secrete but a small quantity of 
milk. Quiet during the day. In the evening more exci- 
table. She sent for Dr. Eno, and explained that mstead of 
having been raped she had been seduced, that she knew the 
father of her child, and could not have the child taken from 
her as her friends proposed. She screamed, and called upon 



96 0B5TZTPJC CLIXIC. 

God and her father to forgive her, and seemed in great dread 
of the punishment which awaited her on acconnt of her lies. 
Althongh she became at length more calm, most of the night 
was passed withont sleep. 

June 12if7^— Still excitable, with a pnlse of 100. The 
discharge from the nteiTis is becoming whitish. Her niTiie 
contains mnch albumen, is acid, specific gravity 1019. and 
the microscope reveals renal cells in abnndance. Her bowels 
were moved bv the sulphate of magnesia. Her milk is de- 
creasing in qnantity. Patient quiet dniing the day, bnt nnable 
to sleep at night. Has no pain, bnt fears that she will have 
a gTcat deal. Addresses her parents and sister as though they 
were present. Bemoans her sin ; is restless, with eyes staling, 
and at times alternately crying and langhing. 

June IZth. — Patient is qniet dming the day ; nrine the 
same as vesterdav, with the addition of casts waxv and finelv 
grannlar. At night pnlv. Doveri gr. viii. were administered, 
bnt withont cansing mnch sleep. She refased for a long 
time to take the Dover's powder, and was suspicions that we 
were ti-ying to poison her. She declared her conviction, that 
she was going to die, asserted that her flesh was rotting, 
called npon vaiions absent persons by name, and was very 
iacoherent generally. She passed her nrine and fsces in bed. 

June 14dh. — Patient qniet dming the day. Pnlse 120. 
Tongne foiTed. TTiine acid, sp. gr. 1015, containing albn- 
men and renal cells. Her breasts were examined, and fonnd 
to contain no secretion. At S.30 p. m. the hot-air bath was 
applied for one hour, althongh the patient conld only be made 
to submit to it with the greatest diflicnlty. She slept bnt 
veiw httle dming the night, althongh having taken pnlv. 
Doveri gr. x., and presented the same ti-ain of symptoms as 
last night. 

June loth. — ^Patient seems a little better, with a pnlse of 
100, and tongne faiTed. ITrine the same as yesterday, with 
the addition of casts waxy and ^q\y grannlar, some having 
grannlar epithelium upon them, also amorphous urates and 



CHLOEOFOEM, ETC., Di PUERPERAL ECLAMPSIA. 97 

dmnb-bell crystals of oxalate of lime. Dr. Elliot xDrescribed 
hydi-arg. bicliloricli gr. -^^ ter in die, on account of its well- 
known virtues in cases of albiuninnria, as well as to correct 
the character of tlie patient's stools, which were pale, fluid, 
and yellowish. One dose of the bichloride was given, and 
aftersvard, by mistake, yV of a gr. of calomel three times at 
the prescribed intervals. Patient slept considerably during 
the day and most of the night. 

J^ime 16th. — Patient slept much of the day. 'No change 
in the urine. Pulse 106. Tongue furred. At 3 p. m. she 
had a copious passage from the bowels, also some pain in 
the abdomen, rather increased by pressure. At 9 p. m. another 
free passage. Gave tr. opii. gtt. xxv. During the afternoon 
and evening the pulse was 140, and skin hot. Patient slept 
some at night. 

J'lme 11th. — Pulse 150 and weak, surface cool. E'o 
change in the urine. Dming the day the patient had six 
fluid and yellow passages from the bowels, in consequence of 
which pulv. Doveri gr, v. were prescribed at 6 p. m., to be 
repeated every three hours. Also egg-nogg was given every 
hour in tablespoonful doses. Patient slept well during the 
iiight. 

Jitne ISth. — Patient has a pulse of 140, and stronger 
than yesterday, with both skin and tongue moist. As her 
bowels had not moved since the Dover's powder was pre- 
scribed, it was suspended at 9 a. m. Her urine the same as 
yesterday. She became very much excited during an un- 
fortunate interview with her sister at noon, and at 3 p. m. I 
found her with a pulse of 150, flushed cheeks, and dry tongue. 
At night she was much excited, and had a return of the 
same mental trouble, and the same inability to sleep which 
we have before observed. 

June 19th. — As the patient had two passages during the 

night, pulv. Doveri gr. v. were administered. Dm-ing the 

morning the patient had a mild dehrium, manifested by 

talking to herself, inability to comprehend conversation, in- 

1 



y» 0B5TETEIC CLIXEC. 

coherency in reply, and striving to get out of bed. At 2 p. m. 
pnlse 160. Tongne diy. Hands and feet cool. Patient 
qnite stupid and unobservant. At 3 p. m. pulse 160. Eespi- 
ration 20. At 4 p. m. pulse so very weak and rapid that it 
was impossible to count it. Eespiration 18 per minute, in- 
terrupted and groaning. From this time onward the respi- 
rations became less and less frequent, and she died at 4.45. 
The family refused an autopsy. 

Case 38. — Puerperal eclampsia j chloroform^ cathar- 
tics / emetic / venesection. — Dr. Wm. A. ZocJcwood, House 
Burgeon. 

Mary Brennan, a native of Ireland, unmarried, aged 24, 
was taken in labor in Bellevue Hospital May 6th, T a. m. 
This was her first child. The presentation was a vertex, 
position L. O. A. The first stage of the labor occupied 
14 hours 30 minutes ; second stage lasted 6 hours 40 min- 
utes ; third, 6 minutes. The child was a boy, and weighed 
9 pounds 2 ounces. The woman was very mach fright- 
ened, and appeared quite nervous during the earlier part of 
her labor, and continued so until she was taken with a con- 
vulsion at 11.30 p. M., May 6th. This was dming the second 
stage of the labor. The convulsion lasted for about three 
minutes, and was characterized by lividity ^of the counte- 
nance, frothmg at the mouth, and biting of the tongue. 
Chloroform was moderately administered during the con- 
tinuance of the convulsion. The patient vomited at 11.45 
p. M. At 12.30 second convulsion. Chloroform again 
given. A spoon-handle had to be held between the teeth to 
protect the tongue. At 2 a. m.. May Yth, third convulsion, 
and fouii:h convulsion at 3.15 a. m. Chloroform each time. 
The head had been slowly advancing dming the past thi-ee 
hours. 4.10 A. M. fifth convulsion, just as the child was 
born. Chloroform again. The placenta came away five 
minutes after the birth of the child, and during the insensi- 
bility after the fit. Child was in good condition. The woman 



99 

slept lialf an hour after this conTulsion. 'No hemorrhage. 
8 A. M., Sunday, May 7th, sixth convulsion. 11.45 a. m., 
seventh fit, eighth at 1 p. m., ninth at 3 p. m., and tenth 
at 3.30 p. M. Chloroform was moderately given during all 
of the attacks. Pulse 116. Eespiration 15. Drowsiness ap- 
pearing to deepen into coma. Examinations of the urine 
showed it to be albuminous. 01. tiglii. gtts. ij. Ice to the 
head. Mustard on the back, over the kidneys. 5 p. m. 
eleventh convulsion, and twelfth at T p. m. Croton-oil did 
not act, and gtts. ij were again given with calomel grs. vj. 
13th, 8.50 p. m. — Convulsion. 9.15 p. m. — Antimonii. tart, 
gr. \ advised by Dr. Taylor. 10 p. m. — Patient vomited, and 
the skin became quite moist. Bled from median-cephalic 
vein 3 xiv. During the bleeding patient had fourteenth con- 
valsion. An injection of soap-suds, castor-oil, and spts. tur- 
pentine was given at 11 p. m., but came away unaccompanied 
by a faecal evacuation. May ^th, 2 A. m. — Fifteenth convul- 
sion, and sixteenth at 5 a. m. T a. m. — ^Woman was lying 
perfectly comatose, and continued so until she died, at 1 p. m., 
May 8th. No autopsy. 

Case 39. — Puerperal eclampsia; no albumen. 

Mrs. G., a well-built, healthy primipara, aged 25 ; con- 
fined January 8, 1856, under the care of Dr. Bogart, and 
safely delivered of a female child. The labor was in every 
respect natural, her health, during gestation, remarkably 
good, though her legs had been much swollen toward its 
close. January 10th. — Dr. Bogart was summoned on ac- 
count of a convulsion, which left her perfectly conscious. 
No milk as yet. Lochia scanty. An eccoprotic mixture 
ordered, and mustard-draughts to her feet. 9 p. m. — During 
Dr. Bogart's absence, and by his. orders, I was sent for in great 
haste. On my arrival I found her conscious, with her tongue 
severely bitten, and learned that she had just recovered from 
a severe convulsion. Pulse feeble and very compressible. 
Urine not albuminous ; no pain over the kidneys ; no swell- 



100 OBSTETEIC CLINIC. 

ing of feet or face. Gave her a tablespoonful of a mixture 
containing equal parts of Hoffman's anod^me, tinctm^e of 
liyoscjamus, and camphor-water, and waited. Another con- 
vulsion of a well-marked epileptiform character soon oc- 
curred, when I gave her chloroform, and kept her under its in- 
fluence for three hours, after which time she slept pleasantly 
for the rest of the night. In the morning her bowels were 
well acted upon, and the milk soon after appearing, she pro- 
gressed miinterruptedly to recovery, and has since done well. 

Case 40. — Puerperal edanvpsia; chloroform ^ forceps. 

. Mary Goodwin, a primipara, aged 32 years, a patient in 
Bellevue Hospital, fell in labor on Wednesday, June 13, 
1855, at about noon. She was attended by Dr. Sawyer, one 
of the house physicians. The pains were efficient, and con- 
tinued during the night. The membranes ruptured on the 
14th, at half-past 8 a. m., and although the expulsive efforts 
continued, the head did not advance. At mid-day she had 
a violent epileptiform convulsion, when chloroform was given 
for about half an hour. Urine now tested, and found albu- 
minous. At 2 p. M. she suffered a second convulsion, lasting 
a minute and a half by the watch. My colleague. Dr. 
Taylor, and myself were then summoned, and decided that 
the woman should be delivered with forceps, which were 
well applied by Dr. Sawyer, and the woman delivered with- 
out much difficulty, full ansesthesia being maintained. The 
placenta proved adherent, and was detached by myself. 
The patient then had a refreshing sleep ; convulsions did not 
recur ; recovery speedy and complete. On the eighth day, 
however, the urine still showed traces of albumen. 

Case 41. — Puerijeral eclampsia ; forceps ; manual dila- 
tation of cervix. 

On the 18th of May, 1856, near midnight, I was sum- 
moned to Mrs. M., living in the suburbs of the city, who 



CHLOROrOEM, ETC., IN PUEEPEEAL ECLAMPSIA. 101 

was in labor witli her fourtli cliild. I found a woman about 
tliirty-eigbt years of age, well built, and healthy-looking^ 
though her face was somewhat puify, and most of her front 
teeth had been lost. She was utterly unconscious; pupils 
moderately dilated and sluggish ; no shrinking from a 
lighted candle held closely to the eyelids; pulse moderate 
in frequency and force; uterus flaccid. A vessel by her 
side contained a quantity of dark fluid which she had 
vomited, and her face and clothes were smeared with the 
same. 

Her friends informed me that she had reached the full 
term of gestation, and had been seized at four in the after- 
noon with a convulsion, followed by a second, though ut- 
terly insensible since the first attack. On vaginal examina- 
tion I recognized the os high up, largely enough dilated to 
admit two fingers, and allowing the head to be recognized 
through the imruptured membranes. Forcible manual dila- 
tation being attempted, I was gratified to find the os yield 
to the efibrts, and well-marked uterine contractions super- 
vening, demonstrated the integrity of that organ. All my 
endeavors to appreciate the foetal heart were foiled by the 
jactitation and extreme restlessness of the patient — restless- 
ness contrasting strongly with the marked insensibility to 
light. 

On questioning her relatives I learned that her feet and 
limbs had been greatly swollen of late, and that she herself 
had dra\vn attention, in a laughing way, to the extreme pufii- 
ness of her face in the morning. Her physician, who hved 
several miles ofi^, had been with her after her first convulsion, 
and had ordered a large dose of calomel and enemata, and, 
not believing her to be in labor, left, after desiring that he 
might be informed of her condition in the morning. 

Repeating my efforts at manual dilatation, I was grati- 
fied to find them successful, and ruptured the membranes. 
Within two hours from my arrival, the os was sufiiciently 
dilated to admit the forceps. Meanwhile the patient had 



102 OBSTETRIC CLIXIC. 

been twice most powerfully conyulsed, presenting all the 
well-known plienoinena of epileptic, puerperal conynlsions 
in their best-marked form, each being preceded by A^omiting 
of a thick, dark fluid, apparently containing blood. Imme- 
diately after the second of these, I placed her in position for 
the forceps. She was then so quiet from its effects, as not to 
need chloroform. I had brought with me, from a number 
of catheters, one of Weiss's gutta-percha catheters, taken at 
hap-hazard, which snapped in the urethra, and could readily 
be crumbled into fragments ; as it was not possible to pro- 
cure another, the bladder could not be emptied, and the 
specimen of mine was lost. 

The head j)resented in the second position of Xaegele, 
and, proving to be small, was withdrawn promptly by thi'owing 
the posterior fontanelle in the hollow of the sacrimi. It was 
a male, born living, and did well. The placenta came away 
readily, after which time the patient remained more quiet 
than before, and I left her between 4 and 5 a. :m:., recom- 
mending that she should be cupped over the kidneys. 

2Loy 20th. — The husband sent for me in great haste in 
the afternoon, two more convulsions having occurred. I 
learned that some croton-oil and enemata had been given 
some few hours after my last visit, and that, dm'ing the day 
of the 19th, she had had two convulsions. Her physician 
had been prevented from visiting her to-day. She was 
sleeping heavily ; on shaking her, and telling her, in a loud 
voice, that she was the mother of a fine boy, she manifested 
some surprise, but almost immediately relapsed into uncon- 
sciousness. This was the fii^t time that she had noticed 
any thing. Unluckily, in my haste, I had brought no cathe- 
ter. Shortly after this visit, she was freely cupped over the 
kidneys, and began steadily to improve. 

June 4:th. — Being in the neighborhood, I called to see her, 
and found her about the house, intelligent but feeble. She 
has no recollection of what occurred, and I was prevented 
from making any inquiiies. She complained voluntarily of 



CHLOEOFOEM, ETC., m PTJEEPEEAL ECLAMPSIA. 103 

paiu in the head, wliicli, she said, had lasted for some time 
previous to her confinement. Her annt told me that the 
urine was now voided in sufficient quantity, thongh it had 
been scanty. They also told me that she had lost several 
days in her reckoning of time, and had forgotten the erection 
of a neighboring shanty, which had been bnilt before the 
confinement. I m-ged continued counter-irritation to the 
lumbar regions and nape of neck. 

Some of the material vomited was preserved in a glass 
bottle and taken to Dr. Clark. This was examined with 
Lis aeciistomed kindness, and found to present the following 
appearances : Blood-corpuscles, mostly colorless, and dwarfed 
almost to a point by exosmosis ; a few only of natural size. 
Generally single, but a small number irregularly grouped. 
Epithelium from the deeper parts of the stomach-tubes, for 
the most part of a brownish hue, becoming deep green in 
color when acetic acid was added ; also, epithelium from the 
oesophagus and mouth. A few masses, or aggregations of 
hematoidin of a dark color. Besides these, granules, which 
appeared to be debris, of an uncertain character. 

Manual dilatation of the os uteri, in parturient women, 
has frequently proved of advantage in my practice. Indeed, 
as we can never estimate its dilatabihty until we have tested 
the matter experimentally, I think that so harmless a meas- 
ure should be more frequently resorted to than is customary. 
The non-recognition of this principle has, probably, cost 
many lives. 

Case 42. — Puerperal eclampsia. — Dr. Reuben CoUb^ 
House Physician. 

Margaret Jenkins; unmarried; primipara; set. 22; fell 
in labor in Bellevue during the night of July 22d, and was 
seen by Dr. Cobb at about 4 a. m., July 23d. Head present- 
ing ; OS dilated to the size of a dollar, thick and undilatable. 
By noon it had dilated to nearly double its size at the first 



104 OBSTETRIC CLINIC. 

examination, but yerj rigid, and not yielding to the strong 
pressure of tlie head. After consnltation with me. Dr. Cobb 
injected about two gallons of warm water steadily within 
the OS. This was done at 2 p. m., and when I saw the patient 
again at 4 p. m., the os was fully dilated, soft, and thin. At 
this time the head had nearly completed the movement of 
descent; the posterior fontanelle was directed to the left 
acetabulum ; foetal heart heard on both sides of the abdomen, 
with the summum of intensity to the left. 'No uterine souffle. 
Membranes ruptured. On moving the head with the finger, 
some liquor amnii would escape. Yagina cool and moist. 

The patient was a strongly-built, well-developed woman, 
with a feeble pulse. The legs being much swollen, and the 
face pufty, Dr. Cobb drew off the urine, which proved to be 
densely albuminous. On questioning the patient, she said 
that her limbs had been swollen for about a month, and that 
her urine had been scanty, although now natural in quan- 
tity. She complained of a peculiar nervous, tremulous feel- 
ing, which had come on the day before, and stated that she 
had seen bright spots and flashes before her eyes. She now 
suffered from headache for the first time since her stay in the 
hospital (a month). Pain complained of when pressure was 
made over the right kidney. Ordered a strong stimulating 
injection of salt water with turpentine. Convulsions appre- 
hended. The question now arose whether the woman should 
be ansesthetized and delivered with forceps, or await the un- 
aided termination of the labor. Unquestionably the symp- 
toms were such as forerun puerperal convulsions in the ma- 
jority of cases. The tremulousness, the headache, and the 
flashes of light, might be considered of doubtful value in 
many women, but this one was perfectly calm, free from 
apprehension or excitement, and admitted the illegitimacy 
of her child in the most natm-al manner. I believed then, 
and believe now, that immediate delivery gave the patient 
the fullest advantage of the obstetric art ; still I determined 
to give her two hours more. 



CHLOEOFOEM, ETC., I^ PUEEPEEAL ECLAMPSIA. 105 

By tliis time, althoiigli the pains were good, no advance 
liad been made; the woman was sighing, and appeared 
weaker ; had vomited a greenish-colored flnid several times, 
and complained more of headache and nervons symptoms. 

Dr. I. E. Tavlor beino- sent for, ao^reed with me in the 
propriety of terminating the labor, and so soon as ansesthesia 
had been indnced, I delivered her with forceps. The oper- 
ation required strong tractive efforts. Child born alive, and 
weighed seven ponnds and a half; she has since done well. 
Placenta gave no difficnlty. The patient was cnpped over 
the kidneys on the next day, was kept warm, and bowels 
freely moved. On the 26th there was no albnmen in the 
m'ine, and she is doing perfectly well. 

Case 43. — Albummuria j intra-uterine Jiydrocephalus ; 
child l)orn alive ; autopsy ; Bellevite Hospital. — Dr. Wm. 
Zee, House Surgeon. 

Isabella Woods, aged 20, primipara, admitted into Belle- 
vne Hospital on the 18th of June, 1864, having just arrived 
from Ireland after a trip of fourteen days in a steamer. 
Strong and muscular woman, who had been accustomed to 
work on a farm. Had been confined to bed during the 
voyage with headache, vomiting, and constipation, which 
she ascribed to sea-sickness. States that she never was ill 
before. Uncertain as to the date of the last menstruation. 
June 20th. — l!^itric acid discloses the existence of albumen, 
although heat alone was not sufficient. Sp. gr. 1024. 'No 
casts were found by the microscope. No other symptoms 
of disease of the kidneys. By direction of Dr. Elliot the pa- 
tient was not allowed meat, and the bowels were kept free 
by salines. June 22d, 5 A. m. — Labor-pains. First stage, 
six hours ; second, four hours. Presentation vertex. L. O. 
A. — Uterine contractions vigorous. Foetal heart on the 
right side, midway between the umbilicus and the ant. sup 
sp. process of ilium. Placenta came away promptly. No 
hemorrhage. Good contraction. 



106 OBSTETEIC CLINIC. 

The cliild made one or two ineffectual efforts to breathe, 
and the heart could be felt beating for five minutes after de- 
livery. 

Post-mortem by Drs. Young and Farrell, in the presence 
of Drs. Elliot and Lee. The size of the head led Dr. Elliot 
to direct that it should be cut off and weighed separately. 
Whole weight of child 9 lbs. 13 oz. Sex, female. Head 
alone weighed 2 lbs. 13 ozs. The head measured trans- 
versely, from centre of parietal bone over to centre of parie- 
tal bone, after removal of the scalp^ 5f inches. Under the 
same circumstances the circumference of the skull measured 
15J inches ; the line being drawn from the protuberance of 
the occipital bone around the head over the frontal emi- 
nences. On opening the skull the ventricles were found 
very greatly distended by a limpid fluid which escaped. 
The amount was not accurately estimated. Some congestion 
apparent, and some clotted blood was found spread over the 
tentorium. This was at first supposed to have escaped from 
the lateral sinus, but on looking more carefully when the 
left lobe was lifted, it was seen to have been extravasated 
on that side, and such was doubtless the case on the right. 
The kidneys were examined microscopically, and found to be 
healthy, as were the thoracic and abdominal viscera. 

Still mthout the autopsy one would scarcely have been 
willing to pronounce the case one of dropsy. The separation 
of the bones was not greater than is often met with. 

Case 44. — BrigMs disease / convulsions in a multipara 
in the sixth month of jpregnancy / chloroform / Barnes's 
dilators. 

Dr. C. L. Mitchell sent for me on the 26th of April, 1863, 

to visit Mrs. ; aged forty ; mother of two children ; who 

had suffered from albuminmia and puerperal convulsions in 
her last confinement, five years before, on which occasion Dr. 
M. had carried her safely through with chloroform. She 



CKLOEOFOEM, ETC., IN PUERPEEAL ECLAMPSIA. lOT 

siifiered habitually from a very aggravated form of dyspep- 
sia, but no observations bad been made of the urine in the 
interval, nor bad there been any symptoms of disturbances 
of that secretion. During the present pregnancy she was 
very desponding, nervous, and apprehensive, and refused to 
make any preparations for the care of the child. For the 
last three weeks she had suffered from amaurotic symptoms, 
and for the last two weeks from intense pain, occurring at 
intervals. The urine had been repeatedly tested for albumen 
during that time, but none had been found until the 25th. 
During that night she had suffered intensely from headache, 
which had been relieved by chloroform and morphia. She 
was comfortable during the morning of the 25th, but in the 
afternoon she awakened from a nap in a restless and nervous 
state, soon culminating in a violent convulsion, dming which 
the tongue was bitten, and which was followed by coma. 
According to her calculation she is now just at the close of 
the sixth month of her pregnancy. Dr. M. had kept her 
moderately under the influence of chloroform, and she was 
sleeping quietly when we reached the house. The skin was 
cool and natural ; pulse equable and good ; no oedema, unless 
possibly some oedema of the lower lids. Some uterine contrac- 
tions had occurred at intervals of fifteen minutes. Careful ex- - 
amination through the abdominal walls had enabled us to de- 
tect a thigh near the fundus uteri on the right side, and subse- 
quently the head on the left side. No foetal movement could 
be provoked by manipulation. The foetal heart, which had 
been distinctly audible before the convulsion, was not now 
heard by either of us. The vagina was relaxed and moist. 
The OS uteri admitted a finger freely, as it generally does in 
multiparae, but was neither dilated nor dilatable. We de- 
cided to introduce Barnes's dilators, and the smallest-sized 
one was introduced at 11 p. m. In fifteen minutes this had 
slipped in the vagina, when the second size was introduced, 
which was expelled by uterine contractions at 12 p. m. The 
membranes were then ruptured, and the ribs and abdomen 



108 OBSTETRIC CLmiC. 

were found to be tlie presenting part. Presently the cord 
prolapsed so as to qnite fill tlie vagina, and was found to 
pulsate very feebly. The child was puny. We could not 
succeed in replacing the funis by manipulation, while the 
maternal cerebral symptoms made us unwilling to place the 
mother in Thomas's position. ]^or was there sufficient dila- 
tability of the cervix to make us willing to tm-n the child. 
Accordingly, without reference to the feeble funis-beats, the 
largest-sized dilator was introduced, and allowed to remain 
three-quarters of an honr, by which time the uterine contrac- 
tions were quite good, and the cervix fully dilated. The 
right thigh was then sought for and brought down, and a 
puny child withdrawn. After the placenta had come away, 
she was allowed to come from under the influence of chloro- 
form, the effects of which had been very happy in restraining 
tendencies to excitement, which would otherwise have culmi- 
nated in convulsions. There was some free uterine hemor- 
rhage ; promptly checked by ice and ergot. 

A specimen t)f the nrine, which had stood for fifteen 
hours, gave a sediment of albumen estimated at one-fifteenth 
of its bulk. J^umerous small-sized casts and fragments of 
casts were found, of which the great majority were pale, de- 
void of epithelium, and sprinkled over with oil-globules. 
Some were waxy. There were also a few crystals of the 
urate of soda. At 11 a. m. of the 27th, vomiting commenced, 
and in nine hours terminated life by exhaustion. There had 
been no flowing since that which occurred early in the morn- 
ing. The matter vomited was an abundant green viscid 
mucus. E'o response to stimulants. ISTo autopsy. 

The dilators in this instance acted with great promptness. 
It struck me at the time that in cases of prolapse of the 
funis, where the cord had been returned, they might be in- 
valuable, either in completing dilatation of the cervix, or in 
affording o, soft cushion to j^i^event fuTther j^rolajpse. 



CHLOEOFOEMj ETC., IN PUEEPEEAL ECLAIMPSIA. 109 

Case 45. — Albuminuria / induction of labor. 

Dr. J. Gr. Perry lias kincllv fnrnislied me witli the following 
liistorj of a case wliicli I saw with him in consultation : 

''Mrs. G ; six months pregnant; aged 34; gave 

birth to first and only child fom*teen years ago ; since wliicli 
time she has been almost constantly under treatment for 
uterine inflammation and retroversion. Her countenance 
bore marks of great mental snfiering, and*the skin was so 
waxy and mottled that I requested she wonld bring me a 
small vial of her morning nrine, for examination. 

" January 8, 186 T. — She called, with specimen, bnt her ap- 
pearance had so changed that I hardly recognized her ; she was 
universally dropsical. Examination of the nrine showed the 
following facts : Deposition of albumen by heat, so solid that 
the tube could be turned upside down without loss of sub- 
stance; specific gravity 1012 ; no casts; great quantities of 
epithehal debris. Quantity of urine passed in twenty-four 
hours, one teacupful; color, dark brown. Was ordered to 
take the hot-water and vapor bath every other night, with 
a drachm of the bitartrate of potash at night, and a solution 
of the bicarbonate of potash and lemon-juice every fourth 
hom\ 

" January 10th. — Prof. Alonzo Clark called in consulta- 
tion, who confirmed diagnosis and approved treatment. 

'^January 11th. — Dropsical condition much improved; 
but there is urgent dyspnoea, distressing palpitation of the 
heart, 120 beats per minute ; and complete loss of appetite ; 
restlessness ; wakefulness at night ; dull headache ; and com- 
plains of seeing ' crystals of water ' floating in the air. Bitar- 
trate and bicarbonate of potash to be continued ; also the bath. 

" January 2Zd. — Marked improvement ; each dose of the 
bitartrate has caused free watery evacuations. Urine increased 
in quantity to one pint in twenty-four hours ; color, lighter. 
Albumen one-quarter of the bulk of the urine. Kenal de- 
bris increased ; no casts. 



110 OBSTETEIC CLIXIC. 

'' Jamiary '^Sth. — E'o albumen present ; quantity of urine 
secreted about normal; dyspnoea still m-gent; pulse 135. 
Cannot lie down from oppression in respiration. Skin bronzed 
and mottled. No sleep for nearly tbirty-six bours. Ordered 
beef-tea and cream. 

"' January Z^th, — Albumen retm-ned in urine, but in small 
quantity. Microscope sbows immense quantities of broken- 
down epithelium ; free nuclei ; but no casts. Pulse 140. 
Patient exceedingly weak, and, at times, mutters to herself, 
as if the mind was wandering. Gets little snatches of sleep, 
lasting a few minutes, and awakes with a start or frightened 
jump. Normal quantity of urine secreted — sp. gr. 1005 — 
reaction acid. Foetal heart-sounds heard ; some movement 
felt. Bitarti'ate and bicarbonate of potash still employed 
every other day, which controls the serous effusions ; while 
egg-nogg, beef-tea, and cream are given p. r. n. 

'■'February 4dJi. — Two hours after taking milk, it passed 
by the bowels almost unchanged. Otherwise about the 
same. Pulse 130. 

'''•February ^th. — 21Sth day of pregnancy. Dr. Elliot 
called in consultation to decide the propriety of inducing 
prematm-e labor, and thought the delay should be a matter 
of days, her condition being so critical, and that the sooner 
labor was induced, the better the chances of the patient's 
recovery, and the saving of the child's life. 

" February Sth. — Patient very feeble and helpless ; pulse 
125. Amount of urine passed about normal. Sp. gr. 1008 ; 
reaction acid. Albumen present. Microscope shows granular 
and epithelial casts ; great quantities of renal epithehum 
and free nuclei. Slight oedema of hands. 

" February ^th. — Commenced operations for inducing la- 
bor. Bowels previously cleared by potash and castor-oil. 
Barnes's dilators employed. The cervix being supple and 
capable of dilatation, I passed my index-finger in and sepa- 
rated the membranes as far as I could. Succeeding in this, 
I introduced two fingers within the canal, and, separating 



CHLOEOrOEM, ETC., IK PDERPEEAL ECLAMPSIA. Ill 

tliem as far as possible, introduced between tliem the second- 
sized dilator. From tbe patient's enfeebled and nervons con- 
dition, I was three times obliged to withdraw the instrument 
to await the subsidence of attacks, which seemed to me 
premonitory of convulsions. Favoring this condition by 
thus withdrawing the instrument and allowing rest, these 
symptoms gradually subsided. 

" 5 p. M. — Size Xo. 1 of dilator introduced. 11 p. m. — 
Cervix fairly dilated ; slight pains felt in back and loins. 
Great relief of the dyspnoea ; patient claims that she feels 
more comfortable than for many days past. 12 m. — Sleep- 
ing quietly. Pulse 136. Dilator removed. 

'^ February 10th. — Passed a comfortable night. Pulse 
stronger ; 130. Ordered warm- water injection in the bowels, 
which was followed by a free evacuation of watery and faecal 
matter. Milk-punch ordered every two hours. 12 m. — Dilator 
again introduced. 5 p. m. — Pains being feeble, ordered 
half a di'achm fluid ext. ergot. Foetal heart still heard, but 
feeble. 7 p. m. — Pains so strong, that the dilator was re- 
moved. Membranes pouted readily. TJ. — Puptured mem- 
branes. Only a few ounces of liquor amnii passed. Thus 
labor commenced, and at 8 p. m., after ten or twelve good 
forcible pains, the child was delivered, living. Pulse came 
down almost immediately to 108. 

" The improvement of the patient went on steadily but 
slowly from this time. Occasionally paroxysms of dyspnoea 
would occur, which would threaten suffocation. 

" August, 1867. — The patient has steadily continued to 
improve. The urine is normal in every respect, though some 
free nuclei are yet observed under the microscope, and her 
general health greatly improved. 

" The child died when three weeks old, from inanition." 



112 OBSTETEIO CLINIC. 

Case 46. — Albuminuria i eclamjosia j death before deliv- 
ery j subsequent inflation of the placenta. — Dr. Wychoff, 
Souse Physician. 

Eliza Garrej — ^native of Ireland, primipara, aged 19, 
robust and well developed, of good habits — states that her 
menses have not appeared "for eight months and a half. On 
Friday, Jnne 10, 1864, at 6 a. m., while awake and yet in 
bed, she was seized with three well-marked general convul- 
sions. She frothed at the mouth, and bit her tongue. There 
was complete unconsciousness, and each convulsion was fol- 
lowed by well-marked coma. There was great capillary con- 
gestion of the face, but the extremities were cold. Cold 
affusions to head and chest, mustard to legs, strong purgative 
enema. Teeth separated by plug. She came gradually out 
from the comatose condition, and for a short time was able 
to converse quite rationally. At 11 J A. m. the convulsions 
returned, and within half an hour she had six seizures, each 
lasting from ten seconds to a minute. These finally yielded 
to chloroform, and did not reappear. Tlie urine was drawn 
with a catheter, and found to be high-colored, of low specific 
gravity, and moderately albuminous. As the enemata and 
the two ounces of castor-oil, which had been given, had not 
produced much effect, two drops of croton-oil were given 
with a prompt and satisfactory effect. She lay in a semi- 
comatose condition, and occasionally replying to questions 
and expressing her wants. Eespiration noisy. 

At 2 P.M. I dictated the following memoranda: "Ab- 
dominal palpitation recognizes that the uterus reaches 
two finger's breadth above the navel. The uterus is hard to 
the feel. Slight uterine contractions occasionally. Foetal 
heart not audible, but the moans and movements of the 
patient forbid a thorough examination. Per vaginam the 
cervix is found to be absolutely undilated and undilatable, 
conical and nipple-shaped, not admitting even the tip of the 
little finger. The head can be distinctly felt through the 



CHLOEOFOEM, ETC., m PUEEPEEAL ECLAMPSIA. 113 

anterior vaginal wall. It is probable that all the waters 
have escaped. Lips blnisb; face slightly puffed. Patient 
can be so roused as to look at you, but not so as to understand 
any thing said. Pulse 110 to 120, good and full. Heart- 
sounds natural." 3J p. m. — Pains recur every twenty min- 
utes, and last from one to five minutes. Calls for drink. 
Nervous symptoms not so strongly marked. Has taken 
nomishment. Chloroform has been administered twice for 
imminent convulsions, as it had been during the morning ; 
but the nervous disturbances are not as well marked. 
Warmth of the body has returned in a measure. 6|- p. m. — 
Up to this time we were sanguine of success, and the deliv- 
ery was not hastened, in the hope that the improvement 
would continue. But now the jactitation increased ; pains 
not noticed ; pulse 112, and weaker ; respiration stertorous. 
Unconscious. Swallowing difficult. Extremities cold. Spu- 
mous fluid from mouth and nose, and death at 8 p. m. 

Autopsy. — I regret to have lost the memoranda of the 
autopsy, which took place twenty-two hours after death. The 
foetus was found in utero, in the most frequent position and the 
customary attitude. There remained four ounces and a half 
of amniotic fluid in utero by measurement. I proceeded in 
the dead-house to display the observations of Dalton by 
introducing a blow-pipe into one of the divided vessels of the 
uterine sinuses, and then inflating first the venous sinuses 
of the uterus, next the deeper portions of the placenta, and 
then the superficial portions. But although I did my best, 
the trial failed for the first time in my experience ; a fact 
which was rendered annoying by my previous prophecy 
of success. In the evening, however, on examining the 
uterus with Prof. A. Flint, Jr., and Prof. White of Buffalo, 
we found that the air had penetrated by this time imme- 
diately underneath the transparent chorion, and we each 
succeeded in readily inflating the whole placenta by Dalton's 
method, and proved the fact by cutting the chorion under 
water and blowino^ a stream of bubbles throuo;h the incision. 



114 OBSTETEIC CLINIC. 

Case 47. — Albuminuria / eclampsia / death from apo- 
plectic clot, with atheromatous degeneration of vessels. — Dr. 
Herman Smith, Souse Physician. 

Anne Miller, admitted to Bellevne, September 18, 
1866, at the close of lier second pregnancy. Feet oedema- 
tons. Urine albnminons. ITo symptoms of nrsemia. Sept. 
26tli, labor commenced, and at 8 p. m. a living male cbild was 
born. Every thing went well until September 2Tth, when 
convulsions occurred. Slie remained comatose after tlie 
first convulsion ; pupils contracted ; respiration gasping ; 
face cyanotic, and died at 2 a. m. of the 28th. 

The autopsy showed a well-contracted and healthy ute- 
rus ; no peritonitis. Liver healthy. Weight 4 lbs. and 14 
ozs. Lungs healthy ; some pleural adhesions on the right 
side. Heart normal. Kidneys weighed 4J- ounces, and were 
healthy under the microscope. Both lateral ventricles of 
the brain were filled with bloody serum ; the third ventricle 
contained serum, and a small clot ; and the fom-th was filled 
with clotted blood. The vessels of the neighborhood were 
examined by Prof. A. Flint, Jr., and found to be the subject 
of well-marked atheromatous degeneration. 

Case 48. — Albuminuria / puerperal eclampsia. 

Dr. J. A. Brady, of Wilhamsburgh, invited me to visit a 
primapara, well built, of healthy antecedents, and within a 
fortnight of her confinement. The doctor had examined the 
mine at intervals, and had found it healthy to within a few 
days before (March 15, 1867), when it became nearly solid in 
ebullition, and displayed very numerous waxy and hyaline 
casts, and free renal cells under the microscope. Passed about 
two pints in the twenty-four hours. The patient's expression 
is good ; head and legs are very oedematous. Acknowledges 
no special trouble except fi'om dyspncea, which prevents 
her from sleeping except in a recumbent postm-e, and occa- 



CHLOEOrOEM, ETC., EST PUEEPEEAL ECLi3IPSIA. 115 

sions great insomnia. She was treated by saline cathartics 
with wine of colchicum until free catharsis had been in- 
duced and she had twice vomited. Hot-air bath for an horn- 
each day. She had well-marked convulsions, but labor was 
safely brought on with the douche by Dr. B., and (Septem- 
ber 29th) she has done perfectly well. 

Case 49. — ATbitminuria ; induction of labor ^ mania ^ 
recovery / subsequent history of the life. 

On the 2d of July, 1861, Dr. C. L. Mitchell, of Brooklyn, 

sent for me to see Mrs. , a primipara of twenty, whose 

last period terminated on E'ovember 20, 1863. Dr. M. 
informs me that she has complained of an unbearable pain 
in the epigastrium, excessive restlessness, unnatural irritabili- 
ty, sleeplessness, and great debility. The patient's exhaustion 
and suffering were such, that unless relieved, in his opinion, 
deatli would soon result. 

She is well built, but very pale and anxious-looking, 
and before her marriage she was under Dr. M.'s care for a 
long time for anaemia, with a loud systolic basic murmur, 
which has now disappeared ; and the heart-sounds are nor- 
mal. There is no oedema norpuffiness of lower eyelids, or of 
any part of the body. The urine nearly solidifies under heat 
and nitric acid, but the specific gravity is high, 1032 ; granu- 
lar casts. There are no head symptoms, disturbances of vis- 
ion or hearing. She complains of pain over the epigastrium, 
and has been vomiting a sour green fiuid. The outline of 
the uterus is not perfectly defined, and we suspect that there 
is some fluid in the abdomen, but the fundus reaches two 
fingers' breadth above the umbilicus. Neither foetal heart 
nor foetal motion recognizable. 

"We agreed that the child was dead, and that Dr. M. 
should induce the labor. The result is presented in Dr. 
Mitchell's own words, as compiled from his notes and letters 
of various dates. 



116 OBSTETRIC CLIIs'IC. 

'• Deae Doctoe : After you left, July 2cl, I used tlie 
Trarm douche to the os and cervix uteri for nearly an hour 
without effect. The patient was exceedingly restless, and 
complained so bitterly of the restraint, that it was necessary 
to desist. 

" While waiting for the messenger to return with youi* 
dilators, I introduced Simpson's sound about three inches, 
and passed it around the foetal head between the uterine 
walls and the membranes, with a view to excite contraction. 
But this seemed as ineffectual as the warm water. 

" After a good deal of delay in procuring sj)onge-tent3, 
one of large size was introduced at 11 p. m. Dming all this 
period chloroform was used, more or less, as called for by 
suffering and restlessness. She passed a comparatively com- 
fortable night, the pain in the epigastrium, which had 
caused more distress than any other symptom, having ceased 
fi'om the time the tent was introduced. That the presence 
of the tent was the cause of the cessation of the gastralgia 
was proved by the fact, that previously to its use, whenever 
my finger was resting against the os uteri in making an 
examination, using the douche, or introducing the sound, the 
pain in the stomach was for the time being absent, but re- 
cmTed when the pressm'e on the os was removed. I think 
this an important fact, as pointing to the cause of the pain in 
the epigastrium. A drachm of fluid extract of valerian was 
administered, with such effect as to render a resort to the 
chloroform less frequent than before. She slept better than 
at any time since Tuesday (June 2Sth), but in no instance 
longer than ten minutes. 

" The ui'ine was rendered completely solid by the addi- 
tion, of nitric acid, only a drop or two of fluid appearing 
when the test-tube was placed horizontally. 

" July Sd. — Face leaden and almost expressionless. Eye- 
lids and cheeks swollen ; jactitation, as in exhaustion from 
great loss of blood ; constantly desuing to be raised aud lifted 
to an easy-chair, and then to be again carried to the bed, 



117 

where it was necessary that the nurse should remain to keep 
the patient from throwing herself out. She was perfectly 
unreasoning and unreasonable, but recognized readily all 
who were present. The os uteri was now so sensitive, that 
she cried out with j)ain whenever it was touched. The 
breath was offensive, the tongue covered with a dark fur; 
the pulse 156 per minute, small, and feeble, and the whole 
appearance was as if the patient would succumb before 
delivery could be effected. On removing the tent, the os 
was foimd dilated to the size of a twenty-five-cent piece, and 
the uterine tissues soft and dilatable. The wax on the 
sponge had not melted, consequently the opening of the 
womb had been accomplished by the vital forces stimulated 
by the presence of a foreign body, and not by mechanical 
distension from the expansion of the sponge. Under the use 
of the dilators the os was in a few hours developed to the 
size of a dollar, and within an hour afterward the child was 
expelled. It was dead, well formed, and of full size for 
seven months. In the evening the pulse had come down 
from 156 to 136 per minute, but remained feeble as before. 
The stimulants and nourishment, consisting of brandy, wine, 
eggs, etc., which had been hitherto used, were still continued. 
The patient slept half an hour without chloroform, but the 
excessive, restlessness required its occasional use. 

" July 4dh. — Has had a comfortable night, the best for a 
week. Pulse, 130. Is more sensible than yesterday, but 
there is no recollection of what has passed. Urine, drawn 
by the catheter, was in large quantity, clear; sp. gr. 1018; 
and, after heat and nitric acid, showing about one-third of its 
bulk of albumen. The face, in the evening, has still a sod- 
den, leaden look, and the urine shows a smaller proportion 
of albumen. 

'' July 5<^A.— The expression of the face almost cheerful, 
and my entrance was recognized with a smile. The face 
and eyelids are less swollen, and the eyes for the first time 
have a natural expression. She is entirely unconscious of 



118 OBSTETRIC CLIXIC. 

what lias passed since Saturday (2d inst.). Pulse, 120. 
Bowels moved five or six times dm-ino- tlie nio;lit, and the 
bladder being evacuated at the same time, made it impossible 
to procm-e any mine for examination. The brandy vras 
discontinued, and beef-tea and chicken-tea snbstitnted for 
the vrine and egg. 

'' tTul?/ 6th. — Eyes natural ; countenance smiling and pleas- 
ant ; pulse, 108 ; tongue covered with a white fiu- ; breath 
no longer disagreeable ; skin natural, and food is relished ; 
the bowels have moved twice, the evacuations still dark and 
thin. A small quantity of mine was obtained, which showed 
only a trace of albumen. 

'^ July ^th. — ^Whole appearance natm-al. Pulse, 108. 
Some tm'bid urine of a sickening odor was obtained, of a sp. 
gr. 1006, which, on the addition of nitric acid, exhibited an 
opaque opal whiteness, and on boiling gave a flocculent deposit 
of albumen one-fom'th of the bulk of the urine, the super- 
natant fluid being of a reddish purple. I was nauseated by 
the smell of the mine, and did not examine it further. The 
absence of my microscope prevented any investigation of the 
deposits. Was called in the afternoon because of the appear- 
ance of new symptoms. She says that she sees a great 
many beautiful sights of fairies in processions, and weddings, 
and is astonished that others do not see them. She ' had a 
talk with a ghost, so tall that she could not see his head, and 
the nm'se never knew any thing about it!' Pulse 120, 
somewhat firm ; tongue not fm-red, but disposed to be dry. 
^urse says, she passes a great deal of water. This of to-night 
has a sp. gr. of 1005, a very small amount of albumen, and 
none of the offensive odor observed in that of the morning. 
All kinds of animal food were prohibited, and farinaceous 
gruels only directed. 

" Jioly 9z5A.— The patient is animated and cheerful ; has 
had no more fancies ; bowels not moved since last evenino;. 
The amount of urine passed in twelve hours is a little less 
than a pint ; about one-fifth of its bulk is albumen, the odor 



:,, IN" PIJEEPEEAL ECLAMPSIA. 119 

a Little sickening, tlie purple color no longer present ; the sp. 
gr. 1005. 

^'Jiily 10th. — Has been taking one-sixteentli of a grain of 
the bichloride of mercury three times a day. Since last 
visit has been extremely restless, complaining of very severe 
pain in the head with a sense of heaviness. The restlessness 
was quieted in the evening by valerian, after which she slept 
well all night, and without strange fancies. Has passed, as 
the nurse estimated, tln^ee quarts of offensive urine during 
the last twenty-four hours. The bowels were moved last 
night and this morning — ^the evacuations being a little more 
consistent and somewhat frothy. The face is again swollen 
and dull, but the eyes appear normal. Tongue redder and 
more dry; pulse, 120. In accordance with the usual sub- 
sidence of the symptoms at this period of the day, her head 
feels much better. Chicken-tea was directed for food, and 
the dose of bichloride diminished to one-twenty-fourth of a 
grain. 

'^ This improved condition continued through the day — 
the headache and restlessness did not return ; food was taken 
with a relish ; the bowels were moved in the evening, with 
evacuations of improved character. 

'' Jidi/ 11th. — Face somewhat less swollen, but expression 
better than yesterday. Tongue paler and less dry, slight 
sensation of heaviness and pain in the head, which she attrib- 
utes to the noise of heavy carts passing early. Thirst less ; 
pulse 124. Feels well, and wishes to sit up. The nurse esti- 
mates two quarts of offensive urine for the twenty-four hours. 
Has not passed water since last evening, and that now drawn 
by the catheter has, for the first time, a urinous odor. For 
the first time, too, the reaction is decidedly acid ; quantity 
of albumen less than day before yesterday; sp. gr. 1008. 
The increase in the specific gravity, I think, is due to the 
diminished quantity of water, and not to an improved state 
of the kidney. Convalescence was from this time fully 
established, and notwithstanding that, in all other respects. 



120 OBSTETEIO CLINIC. 

Jier health was perfect, the specific gravity of the urine did 
not go higher than 1012. 

" Subsequent History. — In a little more than a year subse- 
quently she again became pregnant, and in January, 1866, 
at about the third month, nrsemic symptoms became a source 
of great distress and suffering, chiefly from nausea, headache, 
and prostration. It was partially relieved by steaming, etc., 
but the occurrence of abortion put an end to her troubles, 
and soon she was again about the house, riding out, and in 
all respects doing well. 

" Three months later, in the following April, she took cold 
by getting her feet wet, which brought a return of the same 
symptoms. The urine, treated with heat and nitric acid, 
showed the albuminous portion to be about four-fifths of the 
bulk of the urine passed. Diuretics were administered^ and 
arrested the secretion of urine at once. ' Steaming ' restored 
the function, and in four days reduced the albuminous por- 
tion of the tested urine to one-twentieth of its bulk. The 
urine examined one month later showed one-fortieth of its 
bulk of albumen, but the specific gravity was only 1004. 

" Examinations made from time to time afterward through 
the following year sometimes showed albumen and casts ; at 
others, not ; but the specific gravity at no time exceeded 
1012. Her spirits and general health seemed perfect. 

" During my absence from town in the summer of 1867, 
she was attended by Dr. Hallett, who has furnished me with 
the following memorandum of her last and fatal illness, which 
took place just four years subsequent to her first attack : 

" Beookltn", September 30, 1867. 

" Deae Doctor : I was called in haste to see Mrs. at 

9 A. M. of the 20th July, 1867, and found her dressed, and 
lying in a semi-comatose condition. She had dressed herself 
as usual that morning, and, while giving directions for break- 
fast, complained of her head, and had lain down in the con- 
dition in which I found her. She vomited soon afterward. 



CHLOEOrOSM, ETC., IN PUEEPERAL ECLAMPSIA. 121 

Skin dry and liot. Pulse 96. Eespiration normal. When 
shaken and spoken to londly, she wonld look np like one 
under tlie influence of liquor, and would immediately relapse 
into her former condition. I ordered a stimulating . enema, 
and the application of the yapor-bath, as had been used on 
former occasions. At 12 m. she was in much the same con- 
dition as at my morning visit. Injection had come away, 
but nothing more. Skin diy and hard. Yomited again. I 
ordered one-quarter grain of elaterium to be given every three 
hours, and the vapor-bath to be repeated. 9 p. m. — Her con- 
dition much the same. 'No moistm-e upon the skin, neither 
could any be produced by the vapor-bath. Vomiting con- 
tinues occasionally. No movement of the bowels. At my 
second visit, no water having been passed, I introduced a 
catheter, and drew off about a quart of urine, specific 
gravity 1010, which coagulated by heat and nitric acid to 
about one-sixth of the quantity. 

" During this night Prof. A. Flint was called in consulta- 
tion — about 2 A. M. Her condition was not materially 
changed. As her bowels had been but slightly moved since 
my last visit, one grain of elaterium was ordered, and also an- 
other trial of the vapor-bath. 

"21^^, 9 A. M. — Had vomited the medicine during the 
night. Pulse 108. Skin dry. Coma still the same. No 
movement of bowels, nor had urine passed since introduction 
of the catheter. 12 m. — Condition still the same. She was 
rather more feeble. I again introduced the catheter, but did 
not obtain more than two ounces. Probably had passed her 
water in the bed, as there was a strong, disagreeable odor 
there. 

" She continued in this condition, gradually growing more 
feeble, and vomiting occasionally, until her death, which 
took place at about half-past 2 on the morning of the 23d, 
without convulsion. From the commencement of the attack 
she was unable to speak. It appears that her health had 
been as good as usual until the Friday previous, when she 



122 OBSTETEIC CLIXIC. 

complained of vertigo, ^Meli soon passed off. The next day 
slie got her feet quite wet, and passed the evening at the 
theatre." 

Case 50. — Albuminuria ; eclamjpsia ; induction of labor. 

Dr. C. L. Mitchell, of Brooklyn, called me to the follow- 
ing interesting case in his practice, and has kindly fm-nished 
the history : 

'•' On the 21st of October, 1862, was called to Mi's. , 

then in the last month of her second pregnancy. She had 
intense headache, dimness of vision, oedematons limbs, debil- 
ity, sleeplessness, and great restlessness. For a month previ- 
ously she had been suffering more or less fi'om similar symp- 
toms, for which cathartics and a light vegetable diet had 
been prescribed. During the last three days these had so 
increased in severity that at this time there was imminent 
danger of convulsions, and as no relief was gained but by 
the continued administration of chloroform, I was satisfied 
that the patient's chance for life would be greater if prema- 
ture labor were induced. Dr. Elliot was sent for in con- 
sultation, and at his suggestion leeches were apphed to the 
temples, and a stream of warm water directed against the 
OS uteri. After the leeches were applied, and before the 
douche was used, the patient had two convulsions. Chloro- 
form was again resorted to, and continued subsequently as 
the symptoms would mdicate. TVlien the patient was put 
in position for operating, about one ounce of imne was di*awn 
off, and found to contain a large pro23ortion of albumen. 
Dunng the administration of the douche the patient seemed 
more relieved, and to feel better than she had done for several 
days. Her consciousness was perfect and her vision improved. 
The operation was continued about twenty minutes, dming 
which time the cervix became short and patulous, and the os 
dilated from the size of a dime to that of a half-dollar. The 
relief was so complete that chloroform was discontinued, and 



CHLOKOFOKM, ETC., IX PUEEPEEAL ECLAMPSIA. 123 

the patient slept natm-allj. A third conynlsioii supervened 
in half an hour after, and the inhalation immediately recom- 
menced. At 11 p. M. the warm douche was repeated. Labor- 
pains, pre^-ionslj occasional, became now frequent and severe. 
Os dilated rapidly, and child was born living at 11.20 p. m. 
A fom'th convulsion occurred at 11.50, the chloroform hav- 
ing been suspended during the necessary attention to the 
mother and child. Breathing stertorous; respiration 36. 
Pulse imperceptible at the wrist. Extremities icy cold in 
spite of warm applications. The amount of blood lost was 
but moderate. Half an hour later (12.40 a. m. of 23d), pa- 
tient comatose; sweating; respiration 40; pulse perceptible, 
152 in a minute ; feet and hands cold ; head hot ; face flushed. 
Patient gradually became more quiet under the free use of 
stimulants. Slept almost constantly, and when awake the 
consciousness seemed perfect. The urine, drawn with a 
catheter at 10 a. m., was more clear than that passed pre- 
viously. 

" Examination hy Dr. Austin Flint., Jr. — Acid, specific 
gravity 1022 ; contained an abundance of albumen, and 
showed, under the microscope, a large number of waxy casts, 
many of them with oil-globules attached. They were about 
one-thousandth inch in diameter. ]^o epithelial casts, or 
casts made fatty by debris of epithelium. All the granules 
in the casts were fatty. 

"During the afternoon respiration came down to 32; 
pulse to 120, and quite distinct. A free alvine evacuation, 
of natural appearance. 7 p. m. — Drinks freely. Pespiration 
28 ; pulse 108. Injurious consequences were feared from the 
large quantity of chloroform used during the last six hours, 
and it was gradually discontinued. Patient became very 
restless. Complains much of abdominal pains, chiefly in the 
epigastrium. Sleeps a few minutes at a time, and is very 
violent and abusive when awake. At 2 a. m. (24th) vomited 
an enormous amount of fluid, after which she was much more 
quiet. Indian hemp administered without relief. Occasional 



124 OBSTETEIC CLINIC. 

small clraiights of cold water only allowed. Six to ten hours 
later slie made loud and frequent outcries from pain at tlie 
pit of tlie stomacli, for wliicli an opinm poultice was applied, 
and subsequently belladonna, but without effect. Urine con- 
tains from 60 to 75 per cent, less albmuen than previous to 
labor. Patient perfectly conscious, but remembers nothing 
that had occurred for several days. The patient died from 
exhaustion on the 29th. 

" October, 1867.— The child is still Hving." 

Case 51. — Albuminuria ', edarrypsia i douche i dilators j 
craniotomy. 

Mrs. , aged 20, had been married 210 days, and 

within a fortnight after her last menstrual period. She be- 
came pregnant immediately, and enjoyed better health than 
she had previously done imtil just before her fatal illness. 
The family had noticed that her face was swollen, and that 
she appeared stouter. The hands and feet were not swollen, 
but there was shght oedema over the tibia. Lately she had 
been suffering from flatulent dyspepsia, with pain in the epi- 
gastrium and nausea, and on the evening of the 3d of Octo- 
ber, 1867, these symptoms distressed her so that she went to 
bed, was soon in convulsions, and Dr. Bogart was hastily 
called, who sent for her physician. Dr. Buckley, and both 
continued in attendance. The bowels were freely moved by 
injections, and the fluid extract of senna; chloroform was 
given, and I was added to the consultation at 1 A. m. of the 
Ith. 

The convulsions had been frequent; there was no con- 
sciousness in the intervals except after the first ; tlie breathing 
was remarkably rapid ; the tongue bitten ; there was great 
restlessness. A small quantity of urine drawn from the blad- 
der was high-colored, and deposited about one-third of its 
bulk of albumen on ebullition. 

The cervix was long, not in the least dilated or dilatable ; 
the head presented ; foetal heart inaudible, the loud maternal 



CHLOEOFOEM, ETC., EN" PIJEEPEEAL ECLAISIPSIA. 125 

respiration making auscultation veiy difficult. Labor-pains 
were commencing. The abstraction of blood had been con- 
sidered and declined on account of the pulse, and the great 
danger of the case fully appreciated. Delivery seemed to all 
a matter of equal necessity and difficulty. Within five hours 
Tre had given three large warm uterine douches, had faithful- 
ly tried manual dilatation and Barnes's dilators, and had rup- 
tured the membranes. By seven in the morning two fingers 
could be introduced within the long, thick, and rigid cervix, 
which felt as thouo;h made of " lio-ament." The os was well 
dovm, the head felt, and the fact recognized that the dilatoi^ 
would not work well. They could only be introduced along 
the posterior cervical wall, and were expelled as soon as dis- 
tended. A catheter had been left in utero for a couple of 
hom's. The pains were now feeble. The convulsions, kept 
partly in abeyance at times with chloroform, recurred so 
frequently and so forcibly, that they, and the remarkably 
rapid pumping respiration, were exhausting the patient. 
The pulse, which had ranged from 150 to 160, and had been 
losing force, became so weak that we counted it with diffi- 
culty, and it seemed at one time lost. She appeared mori- 
bund, and the lower extremities became somewhat dusky. 

Delivery was impossible except by perforation, or such 
extensive division of the long, thick, and rigid cervix, as 
could not receive om' approval. We were confident that 
the child was dead, and it seemed that the mother must die 
undelivered. After an hour or so the pulse managed to 
maintain its feeble beat, so as to show that she might yet 
live, at least, some time longer; and it was decided to at- 
tempt delivery by craniotomy, though only after the ap- 
proval of the family in the event of failure to deliver, or 
death during the operation. 

"With Blot's perforator, and Simpson's cranioclast, I com- 
pleted the task, which, considering the condition of the 
woman, the extraordinary rigidity and narrowness of the 
cervix, and the annoyances threatened by spiculge of the 



126 OBSTETRIC CLmiC. 

prematm-e foetal skull, was more painful and difficult than 
any in mj experience. The placenta came away, and the 
uterus contracted well. The woman's strength did not abate ; 
there was still the small, thready pulse, that there was at the 
outset. The convulsions had continued; but, at least, we 
had that hope which attends the fact that delivery had been 
accomplished. "We repeated the injection of beef-tea and 
brandy. She continued to sink, and died at 12 m. 'No con- 
vulsion occmTcd after delivery. 

In this case I washed out the brain with the douche be- 
fore making tractions. 



CHAPTER lY. 

EELATIOXS OF EPILEPSY TO THE PUEEPEEAL STATE. — PUEE- 
PEEAL MANIA. 

Co.se : Epilepsy ; puerperal mania ; subsequent death of child in epileptiform 
convulsions. — ^Patients with epilepsy not specially liable to attacks during 
labor. — Case: Epilepsy; venesection; confinement. — Albuminuria in epi- 
lepsy. — Puerperal mania. — Danger to the child from its mother. — Progno- 
sis; hereditary predisposition. — Asylimas. — Nutrition. — Necessity for tact 
and presence of mind in the management of these cases. — Urine and fseces. 
— Summary of treatment. — Case: Puerperal mania. — Case: Puerperal 
mania. — Case: Puerperal mania. — Case: Puerperal mania. 

Case 52. — Epilepsy ; puerperal mania / death of child, 
8vh8equently in epileptiform convulsions. — Dr. D. McLean 
Fornian^ House Surgeon. 

Margaret Milway, set. 22, U. S. Admitted to Belle vne 
5tli of January, 1867, in tlie 8tli month of lier first preg- 
nancy. Slie gave the history of "epilepsy" for the last 
seven years. Menstruated when fourteen years old, about a 
year before the first attack. Since then she has had about one 
convulsion a month, which always occurred a week before 
or a week after her period. These periods have always been 
regular in every respect until her pregnancy. During the 
last three months of her pregnancy these convulsions, which 
had not ceased, have become more frequent — about four during 
the month. During the twenty-fom- hours before her confine- 
ment she had four convulsions. The labor, however, was 
entirely natural, commenced and ended on the 1st of March. 
Twenty-four hours after the birth of the child she presented 



128 OBSTETEIC CLmiC. 

symptoms of mania, talking irrationally and obscm'ely, and 
manifesting such an extreme dislike for the child, that it be- 
came necessary to take it away from her presence. This 
mania, which was not of a very violent character, lasted for 
a week and then subsided, leaving her so rational that the 
child was restored to her, since when her intelligence remained 
unclouded, and she has cared for and nursed the infant. 

Careful and repeated examinations of her mine have been 
made since her admission, but neither albumen nor casts 
could be found. The treatment has consisted in the bromide 
of potassium (gr. xx ter in die) and tonics. 

April Sd. — One month after delivery. Patient has had 
three convulsions since her confinement, at intervals of a 
week or ten days ; but mother and child are doing well. 

April Sih. — The child, a boy (which weighed 7-J lbs. at 
birth), was seized to-day mth several ill-defined convulsions 
dm'ing the afternoon, and early in the evening presented a 
well-marked epileptiform convulsion, which lasted for five 
minutes. 

April 9th. — Eeftises the breast, lies in a semi-comatose 
condition, but cries when irritated. lO^A. — Several well- 
marked convulsions during the twenty-fom^ hours, lltk. — 
More convulsions. 12th. — Four in rapid succession, dying 
in the last. The child appeared well nomished, and healthy 
in every respect. 

The autopsy, carefully made, revealed no evidences of 
disease. 

The Epileptio is not specially liahle to P%ierperal 
Eclampsia. — Among the most interesting points connected 
with this case is the fact, that this confii-med epileptic had 
no convulsive seizure in her labor. IMy attention was drawn 
to this fact in 1853, in the Lying-in Asylum, in the following 
case. On consulting authorities before that confinement, I 
was gratified to find that epileptic seizm^es were infrequent 
in these patients dm-ing labor ; and so it proved then, and 



EPILEPSY. 129 

now, in the case of Margaret Milway ; and so has it proved 
in mj experience. 

Case 53. — Epilej)sy ; ^venesection ; confinement. 

Alicia ; second confinement, Jnne 21, 1852 ; ver- 
tex ; first position ; 18 honrs' labor ; female child ; healthy ; 
length, 19 inches ; weight, Tf lbs. ; placenta, 1 lb. 4 ounces ; 
diameter, Y inches ; cord, 25 inches in length. 

AKcia has suffered from epilepsy since she was thirteen 
years old, and yet she has had no trouble from any form 
of eclampsia during her two confinements, and during preg- 
nancy the attacks occur at longer intervals. She was bled 
some time before her first confinement, with good effect, and 
on June 5th I took ten ounces of blood from her arm for a 
headache, which would not yield to saline cathartics. (Her 
sister suffered from epileptic attacks up to the establishment 
of the catamenial discharge.) E'o albumen in the urine. 

Albuminuria in Epilejpsy. — A second point of interest is 
the fact that careful examinations of the urine failed to 
recognize any of those conditions which we have seen asso- 
ciated — as the law — with puerperal eclampsia. I^ow, there 
is no difference whatever in the phenomena presented in the 
well-marked attack of epilepsy and those of true puerperal 
eclampsia. It is most probable, however, that examinations 
of the urine of epileptics on a large scale, will show that 
albuminuria does not bear any such striking relations to the 
convulsive seizures as is observed in the eclampsia of the 
puerperal state. We have therefore, undoubtedly, the right 
to attribute them to different influences, and to feel that we 
are closely on the track of the causation of the puerperal 
eclampsia, though that of most cases of epilepsy be yel 
shrouded in mystery. 

Puerperal Mania. — A third clinical fact of interest is 
the development of puerperal mania in the progress of the 
9 



130 OBSTETEIC CLINIC. 

case — mania "unassociated witli any m-gemic blood-poisoning, 
and classical in its character. The hatred of this mother for 
her first-born baby is a phenomenon seemingly irreconcilable 
with the idea of sanity ; and not infrequent in cases of puer- 
peral mania. 

"We have, however, reason to believe that women in 
hospitals .sometimes " overlay " their children intentionally, 
and one case has been shown this month where we suspect 
that such a contingency happened, and the child displayed 
large cerebral extravasations on the autopsy. Nor can we 
witness the indifierence to the fate of their children displayed 
by some women, anxious for the place of a wet-nurse, with- 
out recognizing the fact that there is a difference in the 
maternal love of some sane women. 

I am cognizant of the facts of a case where a young 
mother, with puerperal mania, seized her child suddenly by 
the heels and threw it out of the window. Whenever puer- 
peral mania is suspected, however slight the symptoms may 
be, the child should be carefully watched over, lest its own 
mother should do it harm. 

The prognosis of puerperal mania, according to my expe- 
rience, is very favorable (but no fixed time should be set for 
recovery) ; though it may be modified by evidences of grave 
renal or cerebral disease, or other preponderating influences, 
and especially by hereditary predisposition. This latter history 
is extremely difficult to obtain in private practice, and impos- 
sible in Bellevue. Refined and Christian people may sup- 
press the truth in these cases, even if they do not directly 
mislead the inquirer. I have had occasion to be surprised 
in more than one instance, when informed that aunts, 
grandparents, mothers, or sisters had been unequivocably in- 
sane, though the family, grieving over the young mother 
with puerperal mania, seem to be utterly ignorant of facts 
well known to them and to others. As a rule, cancer, tubercle, 
scrofula, and mania are not remembered in the family circle. 

Still, when we can eliminate the unfavorable influences 



PUERPERAL MANIA. 131 

alluded, to, tlie prognosis is favorable, though the duration is 
always uncertain, and the treatment demands a great deal of 
tact. If the result be favorable, the practice is always 
landed ; bnt if there be delay and disappointment, and the 
reason continue clouded, whatever course may have been 
decided upon is apt to be regarded with disapproval, and re- 
gret felt or expressed that an opposite plan had not been 
followed. Thus, if the patient be promptly withdrawn from 
home, and placed in an institution for the care of the insane, 
without satisfactory and prompt result, the friends may up- 
braid themselves and their advisers for the separation. On 
the other hand, if they retain the patient at' home, and im- 
provement be delayed, they regret that they had not con- 
sented to send her to the asylum where Mrs. So-and-so re- 
covered so rapidly. It is best always to follow the prompt- 
ings of IN'ature, and not to send these patients to asylums if 
they can be well cared for at home, until it is obvious that a 
change may be desirable. It is a disagreeable fact in the 
history of a life that confinement in an insane asylum has 
been necessary. Friends at home, with the best feelings, 
are often so injudicious as to make patients worse. They 
watch over them with such anxiety, such suspicion, and half- 
concealed apprehension, or even fright, as to excite and an- 
noy the patient. The patient, moreover, is apt to feel con- 
straint more acutely in places where she is wont to be obeyed. 
All these facts must be weighed, and it must be remembered 
that a powerful mental diversion is awakened by removal to 
an asylum. There are few of us so badly off that we can be 
as happy away from friends and home as with them, how- 
ever we may think before the trial is made ; and the de- 
velopment of home-sickness in these patients is a healthy 
feeling, and a stimulus to self-control. 

Change of scene may be beneficial in other ways for 
many, and travel fi:om place to place may change the cm^- 
rent of thought, or awaken the patient from apathy. The 
inconveniences are, however, similar to those which may oc- 



132 OBSTETEIC CLINIC. 

cur to the patient retained in the family circle. An addi- 
tional argument for sending these patients far away from 
their place of residence may be found in the concealment of 
their misfortune, and the fact that their subsequent return 
to home removes them from the scenes of their mania. It is 
certain, however, that an American cannot find abroad 
asylums equal to those at home, or men better fitted, if as 
well, to treat the insane, than those in charge of these insti- 
tutions here. 

In puerperal mania the pulse is generally rapid, and may 
be very markedly so. In its progress, mi willingness to take 
food may be developed at any time, as in other cases of 
acute mania, and may seriously complicate the case. The 
exhaustion consequent on pregnancy and confinement, on 
the changes of the puerperal state, on the commencement of 
lactation, joined to the excitability and perpetual chatter, or 
frenzied declamation, so often witnessed, demands that food 
should be administered to support the patient's strength. 
This may be a very difficult task with the patient who be- 
lieves that those she loves best are in a conspiracy with those 
she does not know at all to poison her, whenever the oppor- 
tunity can be found. It may be a difficult task in the sullen, 
melancholic patient who says nothing, but will neither open 
her mouth, nor swallow, if she can help it. The indication 
must, however, be kept in mind, and met with tact and gen- 
tle firmness. 

I have often been struck, in asylums, with the admirable 
manner in which the physicians and attendants quiet patients 
shrieking at the top of their voices, and advancing in a fren- 
zied way upon the visitor. A\^ithout using positive force, or 
seeming to directly oppose the patient's movement, they indi- 
rectly interfere with his advance, and divert his attention: 
The model for all experts is to be found in the old story of 
the man who had ascended to the top of the column at the 
Place Yendome, and found himself sharing the delight of the 
view with a powerful maniac. Being grasped by this charm- 



PTJEKPEEAL MANIA. 166 

iug companion, and ordered to jump witli Mm instantly to 
tlie ground, the unfortunate visitor managed to laugh at the 
proposition, and to suggest that any crazy man could do 
that ; but that he was in favor of descending to the bottom 
by the staircase first, and then of jumping up ! The insane 
man joyfully accepted the suggestion, with a result which 
can be imagined. 

In Bellevue we receive a great many cases of puerperal 
mania, on account of the fact that so large a proportion of 
our pregnant women are unmarried primiparge, and because 
others of the poorest classes, who cannot be controlled at 
home, are sent to the hospital. But we do not keep them 
there if the mania lasts very long, as they are then trans- 
ferred to the Lunatic Asylum on Blackwell's Island, or re- 
moved by their friends. We have not the room or con- 
veniences necessary for those who remain insane after they 
have passed the immediate risks of the puerperal state. 
From all these facts, and from the necessity for keeping these 
patients in the recumbent position for some time after their 
confinement, we may be obliged to use the strait- waist- 
coat, or other methods of restraint, more often than is de- 
sirable on general principles. 

The condition of the urine and of the bowels must al- 
ways be examined into in these cases. Mj own statistics do 
not show so frequent a proportion of albuminuria as others, 
but the coincidence is frequent, and must be treated on gen- 
eral principles. If the amount of urine and urea be suffi- 
cient, and the specific gravity good, the albuminuria offers 
clear indications for treatment and hope. It is to be desired 
that cholestersemia shall be studied in these cases as in 
cases of eclampsia. Constipation must always be appropri- 
ately treated ; and I once saw a case similar to that described 
by Gooch, where a free and large movement of black and 
offensive matter from the bowels preceded the immediate 
restoration to sanity. In all hysterical, excitable women, 
with anomalous nervous symptoms, these very dark dejec- 



134 OBSTETEIC CLINIC. 

tions afford me an indication for treatment, and tlie resnlt is 
often favorable. It is a pitj that the faeces are not more 
generally made the subject of chemical and microscopic 
study. The subject is somewhat revolting, but undoubtedly 
the benefit to humanity will be immense, and the time must 
come when deodorized f^ces will be regularly studied for 
clinical indications. 

The treatment of puerj)eral mania is chiefly expectant, 
and the physician's principal duty is to restore the tone and 
functions of the different organs of the body ; to meet special 
indications ; to promote calm and refreshing sleep ; to sus- 
tain the strength ; to soothe, control, and direct the shattered 
senses by such influences as the patient's position and sur- 
roundings will permit ; to watch for intercurrent and latent 
diseases, especially for meningitis; and carefully to guard 
against liability to relapses. Although, as a rule, recmTence 
of these attacks in successive pregnancies need not be spe- 
cially apprehended, it is well that the patient shall not 
become pregnant too soon ; and where there is hereditary 
tendency to mania, it is better that she shall not become 
pregnant again. 

The ophthalmoscope will probably be found of service in 
these and other cases of delirium and mania. 

Case 54. — Puerperal mania. — Dr. J. J2. Buist, House 
Physician. 

Mary Young ; German ; unmarried, aged 24 ; primapara ; 
entered Bellevue Hospital September 9, 1857. Kothing 
worthy of note in her mental or bodily state until her con- 
finement on the 9th of October, when she had a natural 
and speedy labor. 14^A. — Yisited by the child's father, with 
whom she had a violent quarrel, greatly exciting her, and in 
which she used the most violent and profane language, and 
could only be quieted by persuasion and threats. Dm*ing 
the two following days she remained anxious and agitated, 



PUERPEEAL MANIA. 135 

and talked much to anj and every one. Expression staring 
and unnaturally animated; at one moment sorrowful, and 
then displaying silly levity ; voice unnaturally shrill. Com- 
plained of extreme abdominal tenderness and great dysuria, 
craving relief, though the bladder was empty. Respiration 
hm-ried, pulse 130, and weak. Bowels confined. 01. ric. 
et haust. anod. 20th. — Has uniformly declared herself 
well, but would stop all passers-by with accounts of herself 
and her troubles. To-day she has been disorderly, and has 
accused the nm-se of poisoning her. When approached by 
Dr. Buist she became greatly excited, sprang up in bed, 
talking volubly, with much gesticulation, and accusing him 
of endeavoring to destroy her with 3 ij. of morphia. Spoke 
of her infant with much afiection. At 9 p. m. stole up to 
the rooms of the house staff and shouted the most abusive 
epithets, so as to alarm the patients in neighboring wards, 
and had to be forcibly carried to the cells, when it was 
thought best to separate the child from her, as she had been 
seen stuffing it between the bed and the wall. 22d. — 
Yisited by Dr. Clark and myself. She was now calm, col- 
lected, talked rationally about herself, though she spoke con- 
tinuously and hurriedly as her strength would permit, with 
occasionally a silly expression. Some urine drawn with the 
catheter gave no evidence of albumen. Bowels constipated. 
Five grains of calomel, followed by oil, produced several 
copious stools, dark-colored and very offensive. After this 
large doses of hyoscyamus and Hoffman's anodyne failed to 
procure sleep. 2Zd. — Became violently delirious during the 
night. Broke every glass in the window ; tore up all her 
bed-clothing ; cursed and swore ; sung and talked incessantly ; 
awhile in German and then in English ; and finally had to 
be confined to the bed with belt and handcuffs. This delir- 
ium continued during the night of the 24:th and 25th, raving 
about the man with whom she had lived, and her child; 
that she had just come down from heaven and was expected 
back immediately ; snatches of songs ; and again would re- 



136 OBSTETRIC CLIXIC. 

fuse to keep her bed, as she then saw an old man who would 
kill her. On the 2tl:th the calomel was repeated, with an 
injection of opium, assafoetida, and camphor. Beef-tea and 
milk-pnnch. In the erect posture, pulse 140 ; lying down, 
114. Yoice very hoarse. Constantly tiying to expectorate 
a scanty, tenacious saliva. 2Qth. — Calm and quiet; had 
willingly taken an egg and other nom*ishment. Pulse 116. 
Still wandering and incoherent in conversation. One grain 
of the sulphate of morphia an hour for four hours, without 
producing sleep, though the pupils became much contracted. 
29^A. — Has slept during' the night, but as wild and delirious 
as ever this morning. Obscenity and profanity, self-gratula- 
tion, revenge, hatred, and affection, were uttered by her 
indiscriminately and incessantly. 9 a. m. — Pulse 140. At 
this time I desired Dr. Buist to give her four drops of the 
medicinal hydrocyanic acid eveiy four hours, which she took, 
as I believe, during at least thirty-six hours. At one time, 
by accident, she took eight drops, without ill effects. Its effect 
as an arterial sedative was well shown, for at 1 p. m. the pulse 
feU to 120, and at 5 p. m. to 80. 3 p. m. — Quieter and improv- 
ing in all respects, l^o further treatment. From this date to 
November 14th she grew steadily better, having only occa- 
sional fits of delirium, and at that time needed no restraint. 
Deceniber 12th. — She became delirious again, and almost 
as unmanageable as ever ; and a month elapsing without 
improvement, she was transferred to a lunatic asylum. 

Case 55. — Puerperal mania, 

Mary Murphy ; aged 25 ; first confinement ; February 
24, 1853; head presentation; twenty-four hours in labor; 
female child, living; Lying-in Asylum. Three days after 
confinement she was attacked by puerperal mania of a mild, 
refined type, chiefly refen-ing to literary pursuits, with which 
she could have but slender acquaintance. Pulse ranging 
about 100. She never sought to injure her child, nor 



PDEEPEEAL MANIA. 137 

did slie conceiye any aversion to it. Lactation, lochia, and 
dejections normal. Urine free from albnmen, and presenting 
nothing nnder the microscope but quantities of crystals of the 
m-ate of ammonia, and some oil-globules. She was finally 
removed without any improvement in her condition, though 
there were no apprehensions felt for her life. 

Case 56. — Puerperal mania. 

I remember another case in the asylum, of which I have 
few notes. The patient awoke suddenly in the night, exclaim- 
ing that her house was on fire and her husband " bur-r-ned." 
She remained about a week inconsolable for his loss, con- 
stantly weeping and wringing her hands, and refusing to be 
comforted. The milk, lochia, dejections, and urine afibrded 
me no indication for treatment, and I allowed her to wander 
through the building till the delirium exhausted itself, which 
it eventually did. 

Case 57. — Puerperal mania. — Bellevue Hospital. — 
Francis P. Lyman^ M. P., House Physician. 

M L ; native of Ireland ; aged 21 ; single. Ad- 
mitted September 10, 1861. Brought in by the police. From 
a woman who accompanied her the following history was ob- 
tained : Patient, a robust, healthy Irish girl, was confined 
on the 1st instant, and after a short labor was delivered of 
twins. The mother and children did well until the 5th of 
September, when she began to complain of pain in her head. 
This pain continued until the 8th, when, for the first time, 
she manifested symptoms of delirium, becoming unusually 
talkative, and exhibiting a flow of spirits quite contrary to 
that which she had shown for some days previous. The de- 
lirium became more violent, and on the 9th she attempted to 
take the life of one of her children. When she was admitted 
the delirium was so marked that she was confined to the cells. 
She walked the room, stopping at intervals, and staring Avith 



138 OBSTETEIC CLINIC. 

a fixed gaze at tlie ceiling. She was constantly talking, call- 
ing her mother and other friends, repeating the same name 
in succession many times with great rapidity. Her atten- 
tion was drawn for an instant as the cell-door opened, hnt 
she immediately tm*ned to the wall and continued her rav- 
ings. On being urged to go to bed she declined,- for fear of 
injury, and with the same breath cried out that " her child 
had been killed." Her face was flushed ; eyes bright and 
sparkling ; surface hot and dry. Her pulse was 120, and 
feeble in character. Abdomen flaccid. Uterus contracted, 
but larger than usual. She refused to protrude her tongue, 
and did so only after being repeatedly told to close her mouth. 
The tongue was large, and coated with a white fur at the 
base. As she was flowing constantly, though to a moderate 
amount, an examination was made, and the os uteri found to 
be the size of a quarter of a dollar, and patulous. She resisted 
nourishment with all her strength most obstinately. Beef- 
tea with half an ounce of wine was given by prying open 
her jaws. She was ordered wine, morphia, and ergot, with 
a purgative pill. Sejptemter 10th. — Has not slept. Condi- 
tion the same. The pill could not be given. An enema 
ordered. As she had not passed urine, the catheter was used, 
and three pints drawn. The flow continues. Ice in the va- 
gina. Ergot increased. Heat and nitric acid give no pre- 
cipitate in the mine. Specific gravity 1020. 9 p. m. — Pulse 
96. Bowels have been freely opened. Ofiers less resistance 
to taking food and stimulants, though occasionally force has 
to be used. Morphia every four hours until she sleeps. 
Septe^riber ISth. — Pulse 80. Grew more quiet toward morn- 
ing, and slept an hom\ Since last night has had half an 
ounce of wine every two hours. Bowels open. Passes her 
urine freely. During the day, though still delirious, she was 
more quiet. Has slept a little at intervals during the day. 
Pulse 72. 8epteml)er \^th. — Slept several hours during the 
night. Pulse 60. Mind clear. Confirms the history abeady 
obtained m every particular. Said that she had sent for the 



PUEEPEEAL MANIA. 139 

father of her children, and he could not be found, which 
preyed on her mind for some days before she lost consciousness. 
October 1st. — Has continued to improve. Her pulse has been 
slow, continuing at 48 for three days. To-day she had an 
hysterical convulsion. An enema was administered, bowels 
opened, and she soon regained consciousness, or showed that 
she had not lost it. Urine pale yellow in color; specific 
gra^-ity 1010. No albumen. 

October Zlst. — Has taken the lactate of iron in the comp. 
infusion of gentian. As her health has improved, her hys- 
terical convulsions disappeared. Is apparently perfectly well 
in mind and body. 

Case 68. — Puerjperal mania. — Z>r. Fernandez, House 
Physician. 

Ellen Doyer ; married ; age not known ; primipara ; 
admitted into Bellevae January 9, 1861, with all the symp- 
toms of puerperal mania, unattended with any fixed delusion. 
Pulse 101 ; weak. Surface warm, and inclined to perspira- 
tion. Tongue moist and somewhat coated. Mammse not 
developed. Lochial discharge slight, but otherwise natural. 
Bowels constipated. Urine free from albumen now and 
subsequently. It was necessary to apply the strait-jacket, 
though this was not drawn tight. She was confined to her 
room for ten days, with the exception of two hours a day, 
when she was allowed to walk about under surveillance. 
Her nights were mostly sleepless, though she would occa- 
sionally enjoy short intervals of repose. Opium used but 
twice. Generous diet and stimulants ( 1 ij to 3 iij daily) 
constituted her treatment, with attention to her bowels. On 
the 19th, amelioration of the symptoms became manifest. She 
was calm and subdued, and answered questions readily, and 
subsequently continued to improve. She retained no remem- 
brance of her illness, which seemed due to ill-treatment from 
her husband. Her pulse was always rapid, ranging from 85 
to 100, and once as high as 120. 



CHAPTEE Y. 



AiTTE-PAETIIM HEMORRHAGE. 

Case : Repeated and unavoidable hemorrhages during pregnancy ; induction of 
labor. — Reasons for deciding on an elective operation. — Interference and 
non-interference may be equally successful in certain cases. — Case: Placenta 
prggvia. — Case: Placenta prsevia; tampon and t-vvo-finger version. — Case: 
Forceps for ante-partum hemorrhage. — Case: Placenta preevia; Barnes's 
dilators ; forceps. — ^Why prompt measures -will not always be resorted to in 
time. — Tampon. — Case: Placenta praevia; presentation of foot and hand; 
prolapse of funis ; adherent placenta. — Importance of distinguishing between 
the dilated and the dilatable cervix. 

Case 59. — Bejyeated and unavoidable uterine hemorrhages 
during jpregnancy ; induction of premature labor', sponge- 
tent ', Barneis dilators; douche; manual dilatation. — Dr. 
D. McLean Forman, House Surgeon. 

Mary Wilson, aged 25 ; primipara ; born in tlie United 
States ; single ; was admitted into Bellevue on the 1st of Jan- 
uary, 1867. She states that her last menstrual period ended 
on the 6th of June, 1866. She was perfectly well through 
her pregnancy until about the middle of February, when, on 
rising to her feet from the floor which she was scrubbing, 
she had a discharge of blood from the vagina. This hem- 
orrhage was readily checked by remaining in the recumbent 
posture for a few days. From that time until the 4th of 
April, at various times, and without ascertainable exciting 
cause, she had seven hemorrhages, though she never lost a 
great deal of blood. 

During the night of the 4:th of April, while lying quietly 



ANTE-PAETrM HEMOKEHAGE. 141 

in bed, the hemorrliage reciirred, and tlie patient lost con- 
siderable blood, the flow, however, ceasing spontaneously. 
Xothing abnormal conld be ascertained on the following 
morning. On the afternoon of the 5tli the hemorrhage re- 
turned. Dr. Elliot then saw the patient, made a vaginal 
examination, turned out several clots of blood, and found the 
OS uteri just sufficiently dilated to admit the tip of his finger. 
Foetal heart distinct a little below and to the left of the um- 
bilicus. 'No uterine contractions. Woman not at all pros- 
trated. 

As the period of utero-gestation must be nearly accom- 
plished, and the woman's life was endangered by the 
hemorrhages. Dr. Elliot decided to induce premature labor ; 
and when the patient had been transferred to the lying-in 
ward, he introduced at 3 p. m. a sponge-tent (not waxed), 
the size of the little finger, into the cervical canal as far 
as the OS internum. At 5 J- p. m. this was removed, and the 
OS internum found sufficiently dilated to admit the index- 
finger, and the vertex found presenting. The smallest-sized 
Barnes's dilator was now introduced by Dr. Forman and 
held in situ for twenty minutes ; and during the last ten min- 
utes of its stay several uterine contractions were excited. 
After removing this dilator, two fingers could be introduced 
into the uterus. 

The loop of a larger dilator having broken, and the ute- 
rine efforts having become established, nothing was done. 
Os uteri very rigid. 9 p. m. — Os uteri the size of a quarter 
of a dollar, but very rigid. Pains increasing in frequency 
and severity. Dr. Elliot visited the patient, and ordered the 
warm douche against the inner edge of the cervix. 10 p. m. — 
Membranes have just ruptured during a severe pain. Os 
unchanged. 10 J p. m. — Warm douche for twenty minutes. 

April 6th, 1 a. m. — Pains very severe, and recur at short 
intervals. Yery little change in os. Warm douche (second) 
for half an hour. 4 a. m. — Os the size of a silver dollar. 
Still very rigid. Pains frequent and severe. Third douche 



14:2 OBSTETEIC CLINIC. 

for half au liour. 6 a. m. — Os not so rigid. Head makes 
but little progress. Woman is extremely anxious ; vomits a 
good deal, and is very tired. Chloroform moderately at the 
occmTcnce of each pain. She slept during the intervals. 
The anaesthetic was used in this way for half an horn-, and 
the patient seemed to feel stronger after the short rest which 
it procured, and begged for more. 8 a. m. — Os dilatable. 
Used manual dilatation. Dr. Elliot arrived, repeated the 
manual dilatation, and ordered another, douche. 10 a. m. — 
Anterior lip raised by the hand over the occiput. Fomth 
douche. 

From this time till the completion of the labor at li p. m., 
the case was left to nature. The child was born alive 
(R. 0. A.), weight 4J pounds. The placenta came away 
without difficulty a few moments afterward. The mark of 
partial detachment was designated by a currant-jelly-hke de- 
posit of blood. Its position in utero could not be appreciated, 
by the touch. After delivery, Mary needed careful attention 
for some little time, but did well and left the hospital. 

She was readmitted on the 2Tth of August, complaining of 
great abdominal tenderness and of some obstruction to the act 
of defecation. The uterus was low down and retroverted, with 
a painful small tumor posteriorly and attached thereto, proba- 
bly the ovary. Pelvic peritonitis diagnosticated and treated. 

September 2Sth. — She and her child are doing very well. 

Heasons for deciding on cm elective Operation. — The in- 
duction of labor in this case of recurring hemorrhages during 
gestation was elective, and not of necessity. It would have 
been a justifiable, and possibly a perfectly safe practice, to 
have allowed the pregnancy to go on. It was not a frank 
case of placenta prsevia. Still it was evident that these 
hemorrhages were unavoidable, and that they were related 
to some detachment, or faulty position of the placenta, 
although that organ could not be appreciated by the exam- 
ining finger. The history of the pregnancy made it also 



ANTE-PAETTJM HEMOKEHAGE. . 14:3 

most probable that the woman had nearly reached her term. 
Isovr, under these circumstances, one of these attacks of mia- 
Yoidable hemorrhage might have come on with such severity 
as to blanch the woman, and imperil her life. Should such 
a contingency coexist with a rigid cervix, and with the ab- 
sence of uterine contractions, the lives of both mother and 
child might be placed, within a very short time, in the great- 
est danger. And therefore such considerations justified and 
invited induction of the labor, since the process involved no 
additional risk to either mother or child, but, on the other 
hand, was best adapted to dominate those which then threat- 
ened both. 

Interference and non-interference may he equally suc- 
cessful in certain cases. — My experience has enabled me to 
observe many cases in which it would have been better for 
the patient if prompt and decided measures had been adopt- 
ed at a time when the lives of mother and child were but 
slightly endangered ; and has furnished me with illustrations 
of the great difficulties attending delivery, when the life of 
the mother was hanging in the balance ; as well as of others 
in which the rapid and satisfactory advance of a labor, in 
other respects natural, seemed to mock our apprehensions. 

Case 60. — Placenta prcevia. 

Catherine Mc^N^evens, aged 27 ; fourth pregnancy ; in la- 
bor nine hours. On the 28th of April, 1852, some pupils of 
Dr. Aylette called me to the case on account of the hemor- 
rhage, and the recognition of the stringy placenta within the 
cervix. As the pains were good, os dilatable, and head ad- 
vancing, I recommended ergot, in the conviction that the 
advancing head would answer as a tampon. A living female 
child was delivered without any operation, and the mother 
did well. 

The complications of placenta praevia with premature la- 
bor offer additional difficulties in cases where the cervix is 



14:4: OBSTETRIC CLINIC. 

niiyielding, but nowadays we liave control of the cervix uteri 
in pregnancy, and can generally command its movements. 

The following cases illustrate some of these difficulties in 
placenta prsevia which influenced my decision in the case 
of Mary Wilson. 

Case 61. — Placenta ^roevia / delivery hy two-finger 
version at ohout the seventh mouthy after much trovhle with 
an tindilataUe cervix^ and jgrevious jpartial separation of the 
jplacenta ly the finger. 

Dr. Bishop sent for me on the 24th of July, 1859, in the 

case of Mrs. , pregnant for the ninth or tenth time, in 

whom version had been performed by Dr. B. on a former 
occasion for shoulder presentation. 

She was greatly weakened from loss of blood, the first 
hemorrhage having taken place three weeks before, and after 
that interval of time the present had commenced and con- 
tinued for a couple of days, to such an extent as to demand 
the tampon, which Dr. B. had applied. The os uteri was 
dilated enough to allow the finger, introduced within the 
cervix, to detect the edge of the placenta on the left side. 
The cervix was not dilatable. ]^o change having taken 
place in that respect during the next twenty hours, we ap- 
plied as large a sponge-tent as would enter the cervix, and 
then tamponed the vagina with dampened cotton, and a T 
bandage. This was done in the night, and on the following 
day, at noon, in spite of all that could be done in the way 
of stimulation, it was evidently necessary to terminate the 
labor, although we distinctly declined to guarantee her life 
during the delivery. 

"With one assistant feeding brandy, the task was com- 
menced. The tampon and sponge-tent having been removed, 
it was found that the os was not sufficiently dilated to admit 
the hand. But, fortunately, the position of the child being 
obliquely transverse, I succeeded in touching a foot with the 



aot:e-paetum hemoeehage. 145 

tips of tlie fingers wliich liad penetrated witliin the uterine 
cavitY, and bj external manipulation forced down the limb 
with the other hand so as to obtain a good grasp, and enable 
me, with much effort, to complete a laborious operation, 
the difficulties of which were prolonged to the last b}^ 
the sullen, unyielding grip of the foetal head by the cervix. 
Before proceeding to turn, however, I separated the pla- 
centa as far as my finger could reach, but I cannot tell 
whether much blood flowed during the operation or not ; 
though I do believe that any further loss would have cost her 
her life. The small portion of placenta yet attached having 
been separated, we gave ergot and opium with beef-tea, and 
stimulants freely. She subsequently suffered from an attack 
of peritonitis, for which she was treated by Dr. Bishop, and 
entirely regained her health. 

IcemarJcs. — This case offers an illustration of the best 
methods which we had of controlling this form of uterine 
hemorrhage before the time of Barnes's dilators ; and*it is 
certain that an accurately-adapted sponge-tent in the cervix, 
with the vagina thoroughly packed with dampened cotton, 
cannot be surpassed in efficacy, though they lack certain 
requisites better supplied in the dilators. 

It might have been better for this woman, and possibly 
for her child, if she had applied before for treatment, and if 
the labor had been induced. 

Case 62. — Forceps for ante-partum hemorrhage. 

Ann Martin, aged 25 ; third confinement; April 18, 1852. 
Lying-in Asylum. "When the os commenced to dilate, 
hemorrhage occurred to about a handful of clots. Eotation 
delayed, and after ten hours of labor, the head, which had 
originally presented the occiput to the left sacro-iliac syn- 
chondrosis, displayed a tendency to rotate to the sacrum. 
Foetal heart beating slowly. Having given chloroform, I 
applied the forceps, rotated the occiput to the front, and 
10 



146 OBSTETRIC CLINIC. 

delivered. Tlie child was feeble, but rallied, and they both, 
did well. 

Remarks. — In this case the risks from recurrence of the 
hemorrhage and the likelihood of delay from an occipito- 
posterior rotation, prompted a successful instrumental inter- 
ference, though the operation was elective, and the case 
might have done well if left entirely to itself. 

The risks from recurring attacks of unavoidable hemor- 
rhage, the advantages of Barnes's dilators, and instrumental 
interference, are shown in the following history : 

Case 63. — Placenta ^[yroema ; Barneses dilators ; forceps. 

Drs. Pulling and Wilson sent for me on March 20th, 

1860, to see Mrs. S , a multipara, near the full term 

of her ninth pregnancy. One week previously she had con- 
sulted Dr. Pulling for uterine hemorrhage, which had been 
promptly controlled by ergot and opium. It returned again, 
however, on the 18th, and continued moderately until the 
morning of the 20th, when she flooded to syncope, and Dr. 
Pulling had been obliged to tampon the vagina. When I 
saw her she had been ralhed by stimulants, and the flow was 
checked. She was pale, anaemic, nauseated, and of a highly 
nervous organization, but very weak withal, and much ex- 
hausted by the loss of blood. On removing the tampon, a 
handful or more of clots were turned out from the vagina, 
and the flow continued. Yaginal examination enabled me 
to reach the head through the unruptured membranes, and 
to feel the edge of the placenta distinctly. It was detached, 
and feU over the segment of the cervix, in front of the left 
sacro-iliac synchondrosis. The os uteri measured one and a 
half inches in its diameter, and we all appreciated that it 
was entirely undilatdble. Dr. Pulliug recognized the foetal 
heart in the risrht side of the uterus. There were no uterine 
contractions. It was thus evident that we had to deal with 
serious difficulties. The alternatives were : 



AXTE-PARTTJM HEMOERHAGE. 14:7 

1. Enptiire of membranes, in hope that, with the induc- 
tion of nterine contractions, the head might act as a tampon, 
and meanwhile to re-tampon the vagina. 

2. To detacli the placenta, and be guided by the effect on 
the flow. 

3. To introduce a sponge-tent within the cervix, with or 
without previous rupture of the membranes, and then tampon 
the vagina. 

4. To introduce Barnes's dilators, and then deliver so soon 
as the cervix was sufficiently dilatable. 

The first plan was too uncertain, in the dangerous condi- 
tion of our patient ; the second was contra-indicated by the 
state of the foetal heart; the thhd was the measure on which 
I had relied with safety before Barnes's plan had been intro- 
duced, but now it seemed to us all that the dilators should 
be tried. Accordingly, I introduced the medium-sized one 
of the three which I had recently imported from Weiss, in 
London. Its introduction was unattended with difficulty, 
and it was carried between the head and the anterior uterine 
wall, in all probability detaching the membranes to some 
extent. The sjTinge attached was affixed before the intro- 
duction, and the dilator distended by cool water. In two 
hours we all met again. The dilator had not been displaced 
by her straining efforts in vomiting, nor by her alterations 
in position. The hemorrhage had been controlled. The os 
uteri was now dilated to such an extent that version was 
possible. The foetal head had not been displaced. On re- 
moving the instrument clots followed, which we estimated 
to amount in quantity to the volume of two or perhaps 
three distended leeches. Uterine contractions had now set 
in. While we were deliberating on the next step to pursue, 
the hemorrhage recommenced. The alternatives were now : 

1. To introduce the largest-sized dilator, and fully expand 
the cervix. 

2. To deliver by version. 

3. By forceps. 



148 OBSTETEIC CLINIC. 

Careful examination showed that the hand could pass 
through the cervix, and Drs. Pulling and Wilson inclined to 
version. The foetal heart, however, could not now be heard, 
and hence the necessity for prompt delivery became impera- 
tive, in the hope that it might still be beating. The patient 
was somewhat under the influence of the stimulants we had 
given her, but was too weak, from the loss of blood, for an 
angesthetic. Introducing four fingers within the cervix, while 
the head was steadied at the pelvic brim by Dr. Pulling, I 
resolved to deliver with the forceps, and having introduced 
the blades within the cervix, and having locked them with 
some difficulty so as to seize the head in the diameter from 
the left brow to the right mastoid process, I drew the child 
into the world. The cervix came down before the head, 
instead of dilating, but by pressing strongly upward on the 
anterior lip during the tractions, it finally yielded, and gradu- 
ally allowed the head to pass. The child weighed six pounds 
and a half, and was still-born, without the slightest pulsation 
of the heart. The placenta weighed a little over a pound, 
and its maternal surface was remarkably pale, looking as 
though it had been boiled. The portion we had touched 
was recognizable, and the microscope showed the placenta 
to be healthy. 

Remarks. — The rapidity (two hours) in which this rigid 
cervix was dilated, was an advantage of great moment, and 
we were all deligh'ted with the easy, agreeable, and prompt 
manner in which the os was forced to yield. "When a mul- 
tiparous os uteri is as undilatable as this was after such great 
loss of blood, it is extremely apt to prove rebellious to treat- 
ment, and , it must not be forgotten, that in this case it 
retained its undilatable character to the last, and yielded 
reluctantly to the tractions on the head by the forceps. 

Why jprom/pt Measures wpl not always te resorted to in 
time. — Too many of these cases of unavoidable hemorrhage 
are allowed to place the mother's life in serious danger, and 



AXTE-PAET[JM HEMOEKHAGE. 149 

to peril it' not destroy the life of the child, when more 
prompt and determined measures might have warded off the 
risk to both. 

Still these delays will always occur, because, if the 
mother and child are not saved in cases where the practi- 
tioner takes the responsibility of interference, the following 
criticism will never be withheld : " Perhaps that hemor- 
rhage would never have recurred, or in any event have 
amounted to much, and it would certainly have been better 
to have waited, at least, until the operation became one of 
necessity." 

It is true that no one is justified in proceeding at once to 
such a measure as the induction of labor in these cases, or in 
any other which admits of delay, unless fortified by a con- 
sultation, or sustained by a long and tried exj^erience. And 
unless there is the best reason for expecting that the result 
will be favorable to mother and child, the operation must be 
deferred as long as may be compatible with the safety of the 
mother if the child be premature ; and as an absolutely con- 
trolling duty, if it be non-viable. It must also be deferred 
if in rare contingencies the delivery of the child may be 
rendered dangerous by faulty positions, which can be reme- 
died by manipulation, or may be corrected by time before 
induction of the labor. 

Tanvpon. — In these cases, where the hemorrhage threatens 
the lives of mother and child and the tampon becomes neces- 
sary, it is very often inefficiently applied. The vagina of a 
pregnant woman can never be tamponed without risking the 
induction of labor ; still there may be cases in which we may 
be obliged to resort to this procedure during pregnancy with- 
out desiring such a result. Yarious methods are used. 

My friend and colleague. Prof. I. E. Taylor, recommends 
in his admirable paper on placenta prsevia, published by the 
l^ew York State Medical Society, the use of ''the ordinary 
rolled surgical bandage, two inches wide, which is easily in- 



160 OBSTETEIC CLINIC. 

troduced. The vagina can be packed with it fnllj and com- 
pletely, pressing the soft, long, flabby cervix against the pla- 
centa (thus acting as a free compressor, and preventing any 
hemorrhage taking place internally or externally, and also as 
an oxytocic), and permitting the ping to remain till the pains 
are increasing, or becoming more active, or sometimes even 
till it may be cast ont of the vagina." 

The colpenrynter is preferred by many, and offers great 
advantages from the fact that it can frequently be refilled 
with cool or iced water ; and Dr. Greenhalgh prefei-s an air 
ball covered with spongio-piline. Large sponges are often 
used, and these rendered astringent by vmegsir and other 
agents. It is therefore evident that there is no method which 
is so preeminently good as to rally all practitioners to the 
snpport of its claims. 

If we tampon at all, we must not allow any risk to be 
rmi from the leaking of blood above or by the sides of the 
tampon ; so that while not a drop may flow externally, the 
woman sinks from concealed hemorrhage. In many of these 
cases the loss of a very little more blood will turn the scale. 

From this reasoning I would prefer to ping, in any alarm- 
ing case, both the cervix and the vagina, were it not for 
Barnes's dilators, which dispense with plugging the vagina, 
and combine every requisite, except in those very rare cases 
where the cervix is not sufficiently dilatable to receive the 
smallest one ; or where it cannot be kept in place ; or where, 
as I have said, we may decide to plug the vagina alone. 

In cases of uterine hemorrhage from any source, where 
Earnes's dilators cannot be used, the sponge-tent can always 
be adopted; and lately, in consultation with Prof. Say re, in 
a terrible case of protracted flooding, after a miscarriage, in 
one of the most bloodless women I ever saw, we feared that 
she would die if any more blood should be lost. Under these 
circumstances I first tamponed the vagina and the cervix with 
mass after mass of dampened cotton, introduced and packed 
systematically, so as to thoroughly distend the upper part of 



ASTE-PABTUM HEMOREHAGE. 151 

tlie vagina (a practice tliat I have followed for many years), 
and left with, a feeling of absolute certainty that no flow 
conld take place. Subsequently, when she had rallied some- 
what, we dilated the cervix with a large sponge-tent to remove 
the remains of the retained ovum, and as the manipidation 
was so delicate, and the patient so alarmingly weak, I used, 
on the following night, a finger of an India-rubber glove, 
such as are used in gardening (a plan which has been em- 
ployed by Dr. Emmett), and having introduced it within the 
cervix, injected it to the fullest extent with water, and left it 
in situ. It held its place perfectly through the night. Sub- 
sequently she continued to improve, and the hemorrhage 
never recurred ; but she justified all our apprehensions by 
dying suddenly, in a fortnight, from syncope after exertion. 

Dampened cotton packed within the vagina, with a clear 
recollection of the distensibility of the upper part, is more thor- 
oughly reliable than any other method of packing the vagina. 
Still in advanced pregnancy this will not prevent the risk 
from hemorrhage within the cervix and uterus. 

A trial of the colpeurynter can be previously made, and 
if effectual, is less troublesome and painful to the patient 
than properly-apphed dampened cotton. It moreover offers 
the advantage of being compatible with frequent examina- 
tions, an element of great importance when we are watching 
our opportunity to terminate the labor. 

'Case 64. — Placenta prcevia ; ^presentation of foot and 
hand ; jprolajpse of funis ; adherent placenta. 

Consultation with Dr. Eustace Trenor; report condensed 
from his notes. Mrs. Kane; aged thirty; has suffered for 
several years from bad health and bad habits, and has on 
three occasions flooded seriously after miscarriages. In 
March, when six months gone, she was much excited in 
endeavoring to procure bail for her husband, who had been 
arrested for disorderly conduct. On the next day she 



152 OBSTETEIC CLINIC. 

had a moderate attack of liemorrliage, controlled by Dr. 
Trenor. Two subsequent attacks were controlled by Dr. E. 
Hoffman. 

June 2d. — Sbe was awakened during tbe night by labor- 
pains, followed by liquor amnii, when the pains ceased, and 
she flowed profusely. Dr. Trenor saw her in about three 
hours, and found her rather pale, with a quick and somewhat 
feeble pulse of about 88, complaining of weakness, and some- 
what restless. Os uteri pretty high up, dilated to about the 
size of half a dollar, rigid, thick, and filled with a clot. At 
Dr. T.'s request, I saw her at 7 p. m., when the pulse was 83, 
moderately strong ; lips somewhat blanched ; expression pretty 
*good ; no dizziness or dimness of vision ; voice strong ; abdo- 
men flaccid ; long axis of uterus transverse ; foetal heart in right 
lumbar region ; no clots in vagina ; no flow of blood ; an old 
foetid clot, weighing about 3 ij lying within the os. "Ko cen- 
tral implantation of placenta, and no placenta felt at that 
time. Os uteri dilated to the diameter of 1|- inches, and not 
in any way dilatable. Two fingers passed within detected 
either an olecranon process, or an os calcis. It seemed to 
me most likely the former. The tips of either fingers or 
toes could also just be touched. I thought them most likely 
the fingers. 

11 p. M. — Saw the patient again with Dr. Trenor and Dr. 
Maury. Pulse Y8; moderately strong. Expression better. 
E'o hemorrhage. Os as before. Presenting parts not reached 
more readily, but a flap of the stringy placenta now recog- 
nized hanging over the os on the right side. 

June Sd. — Has vomited once or twice during the night, 
and then slept quietly. ISTo hemorrhage. Condition rather 
better. Slight pains commencing. Os uteri softer. At 
noon. Dr. T. found that dilatation was slowly progressing un- 
der the influence of moderate uterine contractions. Ordered 
3 j ol. ric, as the bowels had not been moved since May 
30th. At about 4 p. m. Dr. Trenor called on me, and stated 
that a loop of the cord was now presenting at the os uteri 



AXTE-PAETUM HEMOEEHAGE. 153 

and pulsating. "Went immediately and placed tlie woman 
most accnratelj in the position recommended by Dr. Thom- 
as, and introducing my left hand entirely within the vagina, 
retm-ned the loop so deeply within the n terns that it conld 
jnst be touched by my two fore-fingers buried within it. I 
thus retained it during two pains, my fingers, in the direction 
given to the superior strait, pointing downward and toward 
the bed. In the interval that followed the second uterine 
contraction, I withdrew my fingers, and found, to my regret, 
that the next pain drove the cord ujp the inclined plane of 
the superior strait into the vagina. A repetition of this 
manoeuvre was attended with a similar result. ]^ot deeming 
it prudent to delay longer, but maintaining the woman in 
the same position, I turned my attention to the os uteri, 
which I now found dilatable enough to admit my hand suffi- 
ciently far to recognize, first, a hand, which I dro]3ped, and 
then a foot, on which I drew (the woman all the while in the 
same position), until I had drawn the thigh into the world, 
when I turned the patient on her back, and rapidly com- 
pleted delivery. The child gasped, breathed, had a good 
color, and gave every sign of reviving, but died in* spite of 
every effort used for restoring life. IS.0 post-mortem. 

The uterus, meanwhile, had firmly contracted around the 
placenta, 3 ij of Canavan's fluid extract of ergot having been 
given immediately after the birth of the child, but Dr. Tre- 
nor called my attention to the fact that blood was flowing in 
a continued stream from the vagina. On introducing my 
hand into the uterus, I regretted to find that the placenta was 
everywhere adherent, except at the fiap alluded to, and re- 
moved it with some trouble, being obliged to leave some 
pieces which could not be detached without bringing the 
uterine wall with them. The flooding diminished, and the 
uterus contracted, but not firmly. 3 iij of ergot and brandy 
given. Her expression, behavior, and pulse, were now such 
as to threaten instant death. Dr. Trenor went, at my re- 
quest, for Dr. Yan Buren, to transfuse the patient. It was, 



164 OBSTETEIC CLINIC. 

liowever, nearly two hours before Dr. Y. B. arrived, and by 
this time the bemorrhage had been controlled. 

During all this time her head was thrown down, arms 
and legs held np, ice over the fundus, while I carefully 
grasped the uterus with one hand, which at the same time 
compressed the aorta through the yielding abdominal walls ; 
and with the other, with the aid of ice in the vagina, irrita- 
ted the cervix, in the hope of reflex action, and thus, with the 
aid of ergot, brandy, chafing, and hot cloths, after an hour 
and a half hard work, rallied the patient, whose pulse had 
twice disappeared from her wrist. The pulse shortly 
rallied after vomiting, and at 8.30 was 120, very feeble, and 
the patient restless, sighing, and tossing about, with a very 
feeble and exhausted expression. 

June ^th, 10.30 a. m. — Since the last note. Dr. Trenor 
has carefully fed the patient on beef-tea, brandy, and opium, 
and she has rallied. Ergot kept in readiness, quinine and 
sulph. acid given, and a blister has been applied over abdo- 
men, to anticipate metro-peritonitis. 

June Qth, 4 a. m. — Dr. Trenor was sent for in haste, as 
the patient had been flowing freely since 1.30 a. m. By the 
time he had reached the house, the patient had taken | jss 
tinct. ergot. A sheet and three smaller cloths were covered 
with blood, and there was a great deal in the bed. The pa- 
tient was blanched, almost pulseless, and too feeble to speak 
above a whisper. On examination, the vagina was found 
filled with a large clot, and the uterus with another, both of 
which were removed. The uterus was flabby and enlarged. 
I ss. more of the tine, ergot, with irritation of the cervix by 
the fingers, brought about a lazy uterine contraction. . Bran- 
dy was given freely, and the uterus compressed by the hand ; 
but the hemorrhage persisting, Dr. T. plugged the vagina 
with strips of oiled linen, and finally brought about a firm 
contraction, which was insured by the hand for three hours, 
when the binder was reapplied. During these three hours 
Dr. T. had kept the head down and the arms and legs in the 



Aiq^TE-PAJRTITM HEMOEEHAGE. 155 

air, and had given brandy somewliat freely. Tlie pnlse, at 
tlie wrist, was now but jnst perceptible, and sensation in tlie 
legs almost gone. She complained of darkness, her lips were 
blue, and the skin of the upper lip and toward the alse of 
the nose acquired a dusky hue. After the application of the 
binder, brandy and beef-tea were given, and she gradually 
rallied, sleeping at first, and afterward becoming restless, 
throwing herself on her side, and from one side of the bed to 
the other, suddenly. 10 a. m. — Pulse 124. Has vomited 
"SiVe or six times, and taken f gr. of opium. 2.45 p. m. — Sud- 
denly attacked with a violent fit of vomiting, throwing off 
in all about a quart of fluid — at first the nourishment which 
she had been taking, and then matter of a dark greenish 
hue, with greenish and very dark flocculent matter in it, 
and without odor. In about fifteen minutes a violent chill 
occurred, which lasted fifteen minutes, and was followed by 
reaction. 

June 7th, 11 A. M. — Tampon removed from the vagina. 
During the night had several hard chills, one of them appar- 
ently excited by swallowing 3 ss of Labarracque's Solution, 
given by mistake. Stomach very irritable ; takes very little. 
Some attacks of faintness. Coughs, with pain in the ovarian 
regions. Pulse 121. 4 p. M.^Pulse 140. Eesp. 30. Ab- 
domen more tympanitic, and tenderness spreading upward 
laterally. Micturition causes severe pain in the hypogastric 
region. The skin is covered with a cold perspiration, and 
dusky, livid spots are appearing on the thorax anteriorly. 
Ordered, every three hours, 3 j of a solution of the sulphate 
of morphia, gr. iiiss.- § iv. of water. 

June Sth, 10 p. m. — Under the influence of morphia. 
Pupils contracted ; patient quiet and sleepy. Spots disap- 
pearing from thorax. Pain less acute, but more extensive. 
Pulse 116, stronger and fuller than yesterday. Respiration 
36. Continue morphia, and ol. tereb. gtt. x. every second 
hour, and an enema containing ol. tereb. 3 ij and 3 j ol. 
ric. in emulsion. 



156 OBSTETEIC CLIOTC. 

6 P. M. — A little more restless. Pulse 134; respiration 
38 ; siibsultus tendin-um. Has had one dark-green fluid evac- 
uation resembling the matter vomited two days ago. Abdo- 
men softer and less tjmipauitic, but not less painful. Lochia 
have almost ceased; tongue becoming dry and brown, with 
disposition to crack. Face very anxious. Lies on her side 
with knees drawn up. 

^t\ 11 A. M. — Pulse 120 ; respiration 58. 

Y p. M. — Died, l^o post-mortem allowed. 

In no cases is the distinction 'between the dilated and the 
dilatahle cervix more important than in tad cases of ante- 
partum hemorrhage. — Let every young practitioner remem- 
ber this practical distinction. They were very forcibly im- 
pressed on me in a fatal case of placenta prsevia which I saw 
abroad. A large piece of sponge was placed in the vagina, 
which was removed at intervals during the day, and the 
operation of version decided against, because the os was not 
found to be any more dilated. Meanwhile the inefficient 
tampon did not prevent the dribbling and clotting of blood 
in the upper part of the vagina ; and, finally, when the con- 
dition of the patient demanded an efibrt, the operator found, 
to use his own words, that " the neck yielded like wet 
paper." 



CHAPTER YI. 



INDUCTIOl^ OF LABOE. 

Methods for dilating the os and cervix uteri. — Douche. — Case: Induction 
of labor with the douche for deformity of brim. — Case: Induction of 
labor with the douche for deformity of the pelvis, and irremediable anterior 
obliquity of the uterus. — Case ; Induction of labor with the douche for 
uncontrollable vomiting in pregnancy. — Douche in rigid os uteri. — Case: 
Dilatation of rigid os by douche. — Case: Dilatation of rigid os by douche. — 
Barnes's dilators. — Case: Rigid os treated by Barnes's dilators, with imme- 
diate contraction of the cervix when these were withdrawn. — Case: Induc- 
tion of labor with Barnes's dilators for hemiplegia, etc. — Sponge, or other 
tents. — Methods for disinfecting these. — Manual dUatation. — Case : Rigid os ; 
douche ; manual dilatation ; forceps. — Methods for inducing uterine contrac- 
tion. — Case: Induction of labor for deformity; imusual difficulty in bringing 
on contraction. — Case : Previous labor of this patient. — The introduction of 
a catheter between the membranes and the uterus. — Case: Induction of 
labor for deformity, with douche, dilators, and catheter. — Case: Induction 
of labor for deformity, with douche, dilators, and catheter.^Separation of 
membranes. — Electric and galvanic currents in the induction of uterine 
contractions ; in amenorrhcea, and as a galactogogue.-^Puncture of the 
membranes. — Medicines for inducing uterine contractions. — Case: Tedious 
labor; ergot; forceps. — Case: Deformity of pelvis ; ergot; forceps. 

In connection with the case of Marj Wilson, ISTo. 59, the 
management of the rigid or unyielding cervix uteri may be 
considered, since Barnes's dilators, warm douches, and man- 
ual dilatation were all employed therein. 

The efficiency of the various and excellent methods 
which we now possess for dilating the cervix uteri has been 
summed up, and their cHnical rank assigned by me in accord- 
ance with my convictions, in a paper published in vol. iii. 



158 OBSTETRIC CLINIC. 

of the " Transactions of the ^ew York Academy of Medi- 
cine" for 1866, which will serve as the basis of these re- 
markSf 

I. The douche is always attainable, always serviceable, 
very often entirely efficient in itself; never painful or dan- 
gerous, when properly used, in cases where there are no con- 
ditions which prevent the risk of fatigue, delay, and some 
exposure which its use demands. These objections, and the 
risk of faulty, direction of the stream, or admixture of air, in 
careless hands, are the main objections that can be raised 
against its use. I should not attach value, from my expe- 
rience with it in localities where puerperal fever is liable to 
be bred and propagated, to any argument that it is liable to 
induce risks of metro-peritonitis. The only influence which 
it may exert for evil on the child is the possibility that its 
faulty use might change the position. And in considering 
this risk, we must not forget the recorded cases where such 
" culhute " has been observed without any recognized cause. 
I should not think of employing it in cases of placenta prse- 
via or dangerous ante-partum hemorrhage ; nor should I in 
other cases apprehend that it would provoke hemorrhage. 
Case 59 illustrates this fact. 

The douche cannot be used efi'ectually unless the stream 
be directed steadily against and within the inner rim of the 
OS uteri. A vaginal douche would be too uncertain in its 
action. Silbert, in his monograph, describes the inefficacy 
of the douche used as a vaginal injection until the stream 
was properly directed against the os uteri. It has occurred 
to me on several occasions to direct, in the practice of others, 
the use of the douche for the purpose of relaxing a rigid os 
and cervix uteri, and to find it ineffectual until similar pre- 
cautions were used. In directing the stream against the os, 
it is to be remembered that an accumulation within the 
uterus is liable to change the position of the child, or, per- 
haps, to develop serious dangers for the mother. All risk of 
this kind is obviated if care be taken to see that the return 



IXDUCTION OF LAEOE. 159 

of water from tlie vagina is about equal to that injected. I 
prefer always to use water of a temperature most agreeable to 
the patient, and to inject one or two gallons at once with an 
ordinary Davidson's syringe, taking care to keep the point 
of tbe fore-finger constantly a little in advance of the nozzle, 
so as to appreciate the direction of the stream. I have 
memoranda of over thirty cases in which I have used the 
douche in cases of rigidity of the cervix interfering with 
delivery, and in cases of the induction of premature labor. 
These memoranda by no means represent my experience in 
the treatment of rigidity alone. It has very rarely failed to 
do excellent service, and in some cases has procured such 
dilatability as to allow of immediate manual dilatation, even 
where there had been no apparent progress. Used in the 
manner which I have recommended, with the patient on her 
back, as we place her for forceps, I have never met with any 
evil results from its use. It has failed me ; it has demanded 
frequent repetitions and delay, but it has proved harmless to 
mother and child ; and I would no more dread to use it with 
such precautions, than an ordinary vaginal injection. 

Case 65. — Induction of ^premature labor with the douche^ 
jprolajpse of funis ; footling ^presentation. 

On the 16th of December, 1853, while Eesident Physi- 
cian of the ITew York Lying-in Asylum, I induced premature 
labor with the douche, under the following circumstances, 
certainly one of the earliest^ if not the very earliest case of 
its class in this country. 

Mary Kipple, healthy-looking, and apparently well-formed, 
had been twice delivered with the perforator and crotchet. 
Pregnant for the third time, she was brought to Prof. Gilman 
for advice, and recommended to the asylum. She was then 
about seven months gone, and the foetal heart distinctly 
audible. The conjugate diameter of the brim, was much 
diminished from projection of the promontory and upper 



160 OBSTETRIC CLINIC. 

part of the sacrum ; pelvis otherwise normal. Drs. Cock, 
Beadle, Metcalfe, and T. F. Cock, physicians to the asylum, 
saw the patient, and they, with Dr. Gilman, concurred in 
urging the induction of premature labor. 

1 selected the method recommended by Kiwisch, from 
previous personal experience of its efficiency in relaxing the 
rigid OS in labor. At 11 p. m., December 16, 1853, 1 injected 
about two gallons of tepid water, in a steady stream, well 
against the os uteri. The instrument used was the admirable 
India-rubber syringe, invented by Higginson, of Liverpool, 
which had been kindly sent to me by Prof. Simpson. The 
patient was placed on her back, with her nates projecting 
somewhat over the edge of the bed, and a large tub received 
the water as it escaped from the vagina. The instrument 
that I used enabled me to direct the nozzle of the syringe 
with one hand, and to regulate its action with the other. 

Decemter 17th, 9 A. m. — The vagina and the os uteri had 
commenced to relax, though the patient had enjoyed a quiet 
night's rest, and felt no symptom of approaching labor. 

2 p. M. — ^Repeated the injection, which neither annoyed 
the patient in anticipation, or performance. The os was now 
softened and the vagina much relaxed, while slight wander- 
ing pains around the back and abdomen denoted incipient 
uterine contraction. 

Dece7nber 18th, 2 a. m. — ^Entering the ward to repeat the 
injection, I found the patient in bed, unconscious of any 
symptom of approaching labor, though the os was now 
dilating very satisfactorily, and the membranes commencing 
to protrude in a somewhat cylindrical form. At 5 A. m. they 
ruptured, when the funis prolapsed to the vulva, and the 
right foot entered the vagina. 

The funis was pulsating vigorously ; and the arguments 
used by Dr. Simpson to illustrate the advantages of version 
in deformities of the pelvic brim, satisfied my mind at that 
time that the pelvic presentation would rather increase the 
chances of safety for the child, were it not for the unfortu- 



IXDUCTIOX OF LABOE. 161 

nate complication present. But the cMld was larger than I 
anticipated (weighing five pounds two ounces), and before 
my best-directed efforts could draw the shoulders and head 
through the contracted brim, all pulsations in the funis had 
ceased, and no endeavors of mine could resuscitate the boy. 

The placenta passed without difficulty, and so little did 
she suffer from the labor, that Mrs. Kipple left the house 
surreptitiously a few days after, rather than await the time 
when she might do so without incurring risk. 

In my judgment, the unexpected size of the infant and 
the unto^vard comphcation of the prolapsed funis alone pre- 
vented the birth of a living child ; while it is evident that no 
labor could advance more insidiously, or entail less suffering. 

It is interesting to note the closeness with which the phe- 
nomena presented simulate those of the most fortunate labor. 
First, relaxation of the soft parts, with increased secretion ; 
the OS then softens, relaxes, and dilates, when the pouch of 
membranes passes intact into the vagina. The first stage of 
labor may be said to be accomplished with the least possible 
inconvenience, and the patient saved in great measure from 
its attendant sufferings ; which are probably productive of 
more annoyance and anxiety than the severer expulsive 
efforts which promise speedy relief to the burden. 

In the following case the value of the douche in dilating 
the cervix and inducing labor is shown : 

Case 60. — Induction of joremature labor with the douche 
in a deformed woman loith marked, irremediable anterior 
obliquity. — Dr. J. Smith Dodge, Jr., House Physician. 

Mary Donovan; Irish; primipara ; aged 30; attracted 
my observation, in the lying-in ward of Bellevue, by her 
deformity. She is four feet and a half high, strongly built, 
with broad shoulders and well-formed limbs. The spine pre- 
sents a well-marked posterior curvature, involving the last 
six dorsal vertebrse, and probably the upper lumbar, forming 
11 



162 OBSTETEIC CLmiC. 

an arc with a prominence of at least an inch. • There is no 
lateral cnrvature, but the projection is greater to the left of 
the spinous processes. Anteriorly the sternum is decidedly 
bowed, rising abruptly outward from the ensiform cartilage. 
Eight chest well formed ; three upper ribs on the left side 
convex at their articulations with the cartilages. 

In conversation I found her of a very low order of intel- 
ligence, and some of her statements were ascertained to be wil- 
fully false, obliging me to rely on my own examination for 
the truth of her condition. It was impossible to ascertain 
the exact date of her pregnancy, but she expected to be con- 
fined some time during April ; and according to my observa- 
tion patients are apt to ante-date the period of their gestation 
to exaggerate their claim on the charity. 

l!^or could a satisfactory history of the deformity be ob- 
tained. According to her statement she has suffered for some 
years from epileptiform convtilsions, though her tongue was 
never bitten. These convulsions have not recurred since her 
gestation. Elidneys. apparently healthy. She remembers an 
attack of rheumatism, affecting the larger joints, lasting for 
some weeks, and accompanied with symptoms referred to the 
heart, though she had no medical care. 

Examination of the chest gave marked pulsation in the 
supra-sternal fossa, above the edge of the sternum ; dulness 
commencing in the third intercostal space, and extending 
directly downward to the stomach ; apex in sixth intercostal 
space, five inches from the mesian line ; loud systolic murmur 
at the base transmitted downward in the mesian line, but 
scarcely audible at the apex ; this murmur recognizable in 
the subclavians, not in the carotids; rhonchus anteriorly 
on the left side, with occasional coarse crepitus in the 
lateral region ; right chest normal ; posteriorly, well-marked 
systolic murmur heard on the right side of the tumor, at the 
site of the posterior curvature. 

Abdominal walls tense ; long axis of uterus in the mesian 
line, but that organ decidedly anteverted, and not susceptible 



ENTDrCTIO^ OF LABOE. 163 

of replacement by position ; wlien on her back, with, tlie 
head unsupported bj pillows, a line let fall from the umbili- 
cus would pass through the symphysis pubis. It seemed to 
me that an inferior extremity could be detected at the fundus 
uteri ; uterine souffle, well marked over the left iliac fossa, 
and with less distinctness on the opposite side. Foetal heart 
not made out at that examination, but distinctly heard on the 
following day in the left lateral uterine region. Satisfactory 
examination of the pelvis rendered impossible, by the con- 
duct of the patient, but certainly not deformed to any extent 
that would greatly interfere with labor ; upper vaginal wall 
decidedly prolapsed; os much retro verted and high up; 
cervix admitting little finger ; no presentation to be detected 
through the os, nor through the cervix. Under these circum- 
stances I deemed it advisable to induce labor with the warm- - 
water douche for the following reasons : [ 

1. That the operation was in no wise dangerous. 

2. That the want of space between the diaphragm and 
pelvis would exaggerate the existing anterior obliquity of the 
uterus, in direct ratio to the development of the foetus. 

3. That, although a primipara, entrance into the pelvis 
of the lesser ovoid of the uterus had already been prevented ; 
the OS much retro verted ; and prolapse of the upper vaginal 
wall induced. 

4. That, in my experience, these unfavorable circum- 
stances in puerperal women, with such deformity, had greatly, 
increased the danger to mother and child. 

5. That these dangers were increased by disease of the 
heart. 

6. That they were still further augmented by a most un- 
fortunate tendency to pelvic cellulitis, and to peritonitis ; m 
the Ijdng-in wards of the hospital, not likely to be removed 
before the warm weather. 

7. That the child was living, and fitted for extra-uterine 
life. 

Consultation. — The patient was examined by Drs. J. T. 



164: OBSTETEIC CLnsIC. 

Metcalfe, I. E. Taylor, and B. F. Barker. Dr. Metcalfe 
sanctioned the operation, and tlionght tlie heart-complication 
of great importance ; he suggested, as possible, that the mm*- 
mnr over spinal cm-yature might he transmitted nterine sonffle. 
On the 9th of April, however, the sound remained unaltered. 
Dr. Barker approved of immediate delivery, but preferred 
the sponge to the douche. Dr. Taylor recognized the dan- 
gers of the case, but preferred that gestation should not be 
interrupted. 

Operation. — The patient consented to the operation, and 
at 3 p. M., March 22, 1857, I proceeded to apply the douche. 
I should have liked to employ the carbonic acid gas, but so 
much time v^as demanded in the operation detailed by Scan- 
zoni, as to make me unvrilling to use it in the present in- 
stance; and long familiarity with the douche, in relaxing 
the rigid os uteri during labor, gave me personal confidence 
in the method that I felt in no other. 

In the operation I was aided by Dr. J. Smith Dodge, Jr., 
one of the house physicians, then in charge of the lying-in 
ward, who gave the patient the most thorough and intelli- 
gent care. The instrument used was the ordinary enema 
syringe, with a piston and tube : and I directed the nozzle 
carefully, so that the stream passed against and within the 
OS uteri ; a matter rendered difficult by the retroversion of 
the OS, and more so by the excessive apprehension and strug- 
gles of my patient, with whom reasoning and persuasion did 
not avail. After injecting about half a gallon, I stopped, in 
the hope that she might become more reasonable with time. 
10 p. M. — Eecommenced, when such were her insane strug- 
gles thaf I had her brought under the influence of chloro- 
form, when about two gallons of warm water were injected to 
my satisfaction, and with appreciable effect; just after with- 
di-awal of the instrmnent vomiting occm-red, preceded by 
violent straining efforts, and immediately afterward a gush 
of waters demonstrated rupture of the membranes. 

Ilarcli 23c7, 7 a. m. — Patient has slept during the night. 



IXDUCTIO^ir OF LABOE. 165 

and offers miicli less resistance to the operation. Abont six 
quarts were injected ; cervix thinner ; vagina cool and relax- 
ing. 2 p. M. — Has had pains in loins and hypogastric re- 
gions, Tvith short but marked intervals; vagina mnch re- 
laxed, cervix verj thin, dilated to abont an inch in diameter, 
and dilatable. 5 p. m. — The nnrse summoned Dr. Dodo-e 
hastily, as she stated that "the waters had broken." Dr. D. 
found her Mly in labor ; pains strong and regular ; quiet 
now, and hopeful ; os fully dilated, head fairly engaging in the 
pelvis ; pulse 152, rising with strong expulsive efforts to 170, 
and rather due, in Dr. Dodge's opinion, to irritability of the 
diseased heart than to general excitement. The head passed 
the perineum about 9 p. m. ; posterior fontanelle turning to 
left thigh ; child made two efforts at respiration, when Dr. 
D. completed the delivery with his finger in the axilla. The 
child was a male, apparently still-born, but revived with 
stimulus to the skin with chloroform, and alternate plunging 
into hot and cold water. 

At this time I arrived, and continued the use of the same 
means, while Dr. Dodge attended to the placenta. Respira- 
tion became natural, and the child was wrapped up in warm 
cotton and blankets; weight 'Q.ve pounds ten ounces, fully 
formed for extra-uterine life ; the frontal 'bone was dejjyressed 
half an inch Mow the parietal. Within half an hour the 
placenta and membranes came away, and the uterus con- 
tracted firmly. 

The mother slept some during the night. Pulse 150 ; 
skin soft; tongue moist; nervous system composed. She 
has since made a good recovery. April ^th. — I satisfied my- 
self that the left side of the pelvis, opposite the cotyloid 
cavity, is narrowed by its approximation to the mesian 
line. 

The child's body became warm, though its uncovered face 
remained cool. Four hours after birth it bled from the nose, 
lost about an ounce of blood, and died in twenty minutes, 
without convulsions. AiUojpsy twelve hours after death. 



166 OBSTETEIC CLINIC. 

Depression, already described, of frontal bone quite evident ; 
extravasated blood beneath the arachnoid, at the posterior 
and convex surface of right hemisphere; clot the size of a 
gooseberry, in the posterior horn of each lateral yentricle, 
and a smaller one in the left optic thalamus ; blood extrava- 
sated at the base of the brain. 

Effect of Obliquity in Mary Donovan. — Certainly what 
I apprehended chiefly with Mary Donovan was that the 
irremediable obliquity of the uterus would render the dip of 
the foetal head into the pelvic brim difficult, by transmifting 
tlie uterine force through the foetal spinal column against 
the upper part of the sacrum, where it would be met with 
resistance in so direct a line as to need, perhaps, the assist- 
ance of art — certainly to protract the labor. 

The correctness of this view appears to me to be demon- 
strated by the cause of the child's death, even under the 
favorable circumstances of its birth. On reviewing the case, 
it will be seen that the obstacle to the passage of the foetus 
could not have arisen from the cervix, for the os was fully 
dilated by the time that the expulsive efforts were called into 
play ; and as the presentation was the most favorable (left 
occipito-anterior), it is certain that the depression of the 
frontal bone must have been occasioned by pressure against 
the posterior pelvic wall. It is evident that it could not have 
occurred before labor set in, for the head had not entered the 
pelvis, as it so frequently does in primiparse. 

Burns has remarked that Daventer, who was a candid 
and experienced man, has, perhaps, made the moderns too 
inattentive to uterine obhquities, by going too much to the 
other extreme. 

Moreover, in many of these cases we may say with 
Mauriceau : " Celle qui est petite ou trapue, ou contrefaite 
comme la bossue, n'a pas la poitrine assez forte pour faire 
valoir ses douleurs et les pousser en bas." 



INDUCTION OF LABOR. 167 



Case 67. — Uncontrollcible vomiting in jpregnancy / ex- 
haustion i induction of jpremature labor with the doucJie. — 
Drs. E. TF. Lamhert and N. Barron^ Bellevue. 

Ellen McGowan, aged 32 ; Irish ; married ; ninth preg- 
nancy ; has never miscarried, and has had easy and good 
labors, Abont January 1, 1858, was first taken with nausea 
and vomiting, which became persistent. For three weeks 
the material vomited was bitter, and often green ; afterward 
not bitter. Always constipated ; bowels only moving after 
the administration of medicines. Bismuth, lime-water, hy- 
drocyanic acid, bicarbonate of soda, chloroform, creasote, and 
hyposulphite of soda internally, bhsters to epigastrium, simple, 
and sprinkled over with morphia, and many other remedies 
were tried, with little or no effect. Supporting treatment 
was resorted to by the mouth and by the rectum, but she 
steadily lost ground from the date of her admission. Feb- 
ruary 13th a consultation was called, and a second on the 
15th, in both of which Dr. ElKot's desire to induce prema- 
ture labor was not supported. On the evening of the 16th 
Dr. Metcalfe sanctioned the operation, and she was trans- 
ferred to the lying-in ward at half-past 9 p. m. She was then 
in a very critical condition, almost exhausted, but refused to 
be carried, and walked between two assistants. She sat in a 
chair several minutes without being noticed, as three othei* 
deliveries were going on at that immediate time. Pulse 104, 
small, and feeble. On vaginal examination the os uteri was 
found quite patulous ; head low down and movable ; plenty 
of liquor amnii. Foetal heart distinct. 10.45 p. m., a warm 
douche of one and a half gallons played against and within 
the uterine orifice, and patient immediately covered up warm 
in bed. Two tablespoonfuls of iced champagne were given, 
and immediately rejected. February 17th, 3 a. m. — Several 
warm douches, followed by hot air bath, as she complained 
of chilliness. 7 a. m., pulse 94, and of the same character. 



168 OBSTETEIO CLIXIC. 

Patient has refused the champagne, asked for tea, and occa- 
sionallj for water. Fcetal heart not now perceptible. 9 a. m. 
Dr. ElKot's visit. Pains are commencing, regular, and of 
some force. Uterine action commenced before the patient 
was aware of it, and when told of the fact, denied that she 
had any pains. At 10.20 the membranes were ruptm-ed. 
Foetal heart again heard. Child born, living, at 2.45 p. m., 
apparently between seven and eight months, small and puny. 
Injections of brandy and the wine of ergot given. Uterus 
contracted well. At 4 p. m. the placenta remaining wholly 
within the uterus. Dr. Elliot introduced his hand and foimd 
it entirely adherent to the anterior wall. 'No hom'-glass or 
irregular contraction. Pemoved with some difficulty, but 
without hemorrhage. Endeavored to give her milk in small 
quantities, which she relished, but continued to sink, and 
died a little after midnight ; the infant having died just be- 
fore. Intelligence uninterruptedly clear; vomiting never 
having been checked. Autopsy by Dr. Lambert thirty hours 
after death. Head not examined. 

Chest. — Pight lung healthy, with a small cicatrix at the 
apex. Left lung everywhere adherent from old pleurisy, at 
apex a few unsoftened tubercles. Heart healthy. 

Abdomen. — No peritonitis ; stomach contained no fluid. 
Mucous membrane has a slight greenish-yellow tinge, and 
somewhat mammillated. No softening, except in greater cul- 
de-sac ; no traces of inflammation. Spleen natm^al in color, 
size, and consistence ; liver of normal size and color ; gen- 
eral and marked softening ; posterior and under sm-face of a 
semi-fluid and pultaceous consistence. In attempting to re- 
move the organ the fingers would sink their entire length 
upon the slightest pressm^e. Gall-bladder natural. Kidneys 
pale, flabby, and soft ; secreting portion apparently normal. 
Uterus well contracted, but the tissue easily lacerated. Cav- 
ity contained a few small coagula. IsTo signs of inflamma- 
tion. The microscope showed that the liver-cells contained 
no unusual amount of fat ; some cells were partially disin- 



INDUCTION OF LABOE. 169 

tegrated, and free granular matter was very abnndant. 
Some kidney-cells somewhat granular. 

My service in Bellevue always supplies me with addition- 
al clinical illustrations of the value of the douche, nor has the 
present one been an exception to the rule. Among many 
cases in my possession and on record, the following happen 
to present themselves at the moment, and are published, not 
on account of their rarity, but because they serve as types of 
so many that have come under my observation. 

Case 68. — Rigid os jpromptly dilated hy the warm 
douche. — Bellevue. — Dr. Henry C. Eno^ House Physician. 

Catharine Daker, born in E'ew York ; aged 20 ; single ; 
entered Bellevue Hospital during the ninth month of her 
first pregnancy. At 4 o'clock, a. m., June 20, 1865, her wa- 
ters broke, but she had no pains until the morning of June 
21st. They began to be severe at 12 m. The patient did 
not come under observation until 8 p. m. of the same day. 
The 03 uteri was then about two inches in diameter, but 
thick and very resisting. At 8 a. m., June 22d, the os was 
about three-quarters dilated, but very hard and rigid, and 
continued so, the head making no advance during the morn- 
ing. At 2.15 p. M., the patient was feverish with a pulse of 
110, and still no advance. At this time, in accordance with 
Dr. Elliot's directions, two gallons of warm water were 
thrown against the os, which ahnost instantly became softer. 
At 3 p. M. was fully dilated, and at 3.53 p. m. the head of 
the child was delivered. 

Case 69. — Rigidity of os uteri treated hy warm douche. 
— Dr. Mead^ House Surgeon. 

Joanna Sharkey ; aged 28 ; primipara. Labor-pains first 
felt May 13th, 5 a. m. When examined at 8.30 p. m., os was 



170 OBSTETEIO CLINIC. 

dilated to about the size of a half-dollar ; the membranes 
imriiptm-ed ; presentation, cephalic. The os did not dilate, 
and at 8 a. m., May 14th, the membranes were ruptm-ed by 
the nterine contractions. 12 m.— Os still rigid, nndilated and 
nndilatable. A gallon of warm water was now injected 
against the internal surface of the os uteri. Three hours later it 
was fully dilated, and the head had engaged in superior strait. 
Position, L. O. A. The pains now became regular, and 
she was dehvered at 4.45 p. m. of a female child, weigh- 
ing 8J- pounds. Cord around the neck. The child was 
asphyxiated, but alternations of hot and cold baths soon 
brought about regular respirations. 

II. Barnes's Dilators. — These can always be employed 
with facility where two fingers can pass into the os ; and are 
susceptible, in favorable cases, of earlier use. They are, per- 
haps, more widely useful than the douche, and are applica- 
ble in cases of hemorrhage, jactitation, and insubordination, 
where the douche cannot be used. They are more certain, 
and can be relied on beyond any other measm-e to rapidly di- 
late the cervix, and allow the confident anticipation of a very 
rapid operative delivery within a few hom'S. They combine 
facility of introduction, facihty of retention, hydrostatic 
pressure, application of heat or cold, compatibility with fre- 
quent vaginal examinations, with comparative safety against 
internal uterine hemorrhage. 

They are liable to be di'awn, . in exceptional cases, into 
the uterus which has not lost its spheroidal form ; to rujpture 
the membranes too early ; and possibly to induce a change in 
the child's position. The head may, however, be so forcibly 
pressed against the rigid os as to prevent their introduction. 
They may be expelled at once when the os is well dovm, 
and directed forward, and when they can only be introduced 
along the posterior cervical wall. It has occm-red to me 
that in cases where the funis has been replaced in utero 
while well pulsating, and a rigid cervix or other conditions 



mDFCTION OF LABOE. I7l 

interfere with delivery, these dilatoi's, well distended, offer 
the best gnarantee against a reproduction of the prolapse, 
while facilitating the prompt delivery. 

It is probable that their use will always supersede that 
of sponge or other tents in midwifery, except in very rare 
contingencies, and greatly diminish the necessity for manual 
dilatation, which is always liable to be abused in inex- 
perienced hands. 

It is probable that the hosts of men who delight to at- 
tach their names to a serviceable invention, will yet so im- 
prove these dilators as to do away with some inconveniences 
in their introduction, and applicability to variations in the 
character of the cervix and the presentation, and render them 
less likely to ruptm-e and wear out. 

The finger of an India-rubber glove will serve an ex- 
cellent pm'pose in cases of rigidity, where the smallest- 
sized dilator cannot be introduced ; and, as I have shown in 
this work, is well adapted to bad cases of flooding in mis- 
carriage, where the uterus is yet small in size and rigid, and 
especially where it is desirable to dilate the cervix, and 
withdraw any retained part of the ovum. 

Some cases have come u:nder my observation in which, 
while these instruments will rapidly dilate the cervix, the 
latter contracts promptly, and even immediately after their 
withdrawal, almost as though it were made of India-rubber. 
This state of things has embarrassed me in cases where a 
prompt forceps delivery was imperatively demanded, and is 
also represented in Case 71, where no operation was indicated 
or demanded. 

It follows, therefore, that the cervix uteri may represent 
types of rigidity, differing in degree, and varying in the de- 
grees of thickness of the cervix. It may offer a rigidity which 
is only apparent, and can be at once dilated by the hand — a 
dilatable, but not dilated or dilating os. And on the other 
hand the os may be dilatable, but may spring back when 
the dilatins: force is withdrawn. 



1Y2 OBSTETEIC CLINIC. 

Case TO. — Induction of jprennatuTe labor with Barnes's 
dilators. 

The patient was a multipara, wlio in a second pregnancy 
had suffered from eclampsia. The urine, however, was but 
little affected, and diligent search had only rarely shown 
any albumen, and a cast or two. She became hemiplegic, 
and had choreic convulsions, with tendencies to cerebral 
congestions. She had been seen by Drs. Yan Buren, Clark, 
Swift, and Echeverria, and, I believe, by others. Pregnant 
again, my opinion was asked, and given in favor of delivery 
at any time in which the mother's life became seriously com- 
promised; but if care and treatment prevented this risk, 
then my opinion was decidedly in favor of bringing on labor 
at the eighth month, as I thought that she should in any 
event be spared the dangers and delays of the last month of 
pregnancy. Accordingly, this unfortunate woman went on 
with her pregnancy, and at the eighth month I commenced 
the induction of labor with Barnes's dilators on the 9th of 
June, 1863 — hehig^ in my Mief^ the first case in which they 
have heen employed for the induction of labor in this coun- 
try. At 9 A. M., the OS was high up, and reached with some 
difficulty. The finger, when forced through, could detect a 
cranial presentation. Cervix uteri thick and long. Man- 
aged to introduce the smallest-sized dilator. 12 m. — The 
first is nearly in the vagina ; relaxation of the cervix and 
vagina has commenced. Introduced the second size, into 
which I could inject three syringefuls of water. 2 p. m. — 
This was slipping in the vagina. Pains have commenced ; 
some show. 4 p. m. — 'B.q pains. Reintroduced the second 
size, and injected it with six syringefuls of water. 7 p. m. — 
Dilator found in the vagina, where it had probably been 
forced by some strong expulsive pains which had occm-red 
at five o'clock, and had suddenly ceased. Os uteri now 
nearly fully dilated, though not absolutely dilatable. Slight 
pains recognized by abdominal manipulation, and by the 



EN'DrCTION" OF LABOE. 173 

finger pressed against the bag of waters, wliicli was quite 
thin, would become tense with pain, and was commencing 
to protrude within the cervix uteri. Yagina relaxed and 
moist. I was fearful of rupturing the membranes if I rein- 
troduced the dilator within the cervix. Accordingly I intro- 
duced the largest size, fully dilated, within the vagina, and 
reinjected it about 10 p. m., when I left it in all night, during 
which she had some pains and some sleep. 

June 10th, 5 A. m. — Os fully dilated, vagina relaxed, mem- 
branes now protruding ; head not advanced ; foetal heart beat- 
ing. I then introduced one-half of a No. 9 flexible catheter, 
with a string attached, and left it in situ between the uterus 
and membranes. In the course of the day the labor termi- 
nated naturally. The child was living, and has done well. 
The mother is living, and has improved in health. 

Hemarks. — The principle which I advocated in this case, 
of allowing the pregnancy to go on in the interest of the 
child until fully viable, and of then bringing on labor in the 
interest of the mother, applies to a vast range of cases where 
diseases of the kidneys, heart and blood-vessels, lungs and 
respiratory apparatus, nervous system, or comphcations, as 
from the presence of abdominal tumors, motive a consulta- 
tion for danger to mother and child. It applies also to cases 
of successive occurrences of fatty placentae in different preg- 
nancies. 

Case 71. — Rigidity of os uteri treated hy JSarnes's dila- 
tors and douche y contraction of cervix after withdrawal of 
the dilator. — Dr, Mead^ House Surgeon. 

Ellen Dealy; set. 35 (?); primipara; physical signs of 
emphysema present and occasioning much distress. Labor- 
pains commenced May 29th, at 8 A. m. ; but she did not go 
to the lying-in ward of Belle vue until May 30th, at 12 m. ; 
when she stated that she had not felt any foetal movement 
for a week. Foetal heart inaudible. Os uteri admits the 
index-finger, and is rigid and imdilatable. Dr. Elliot saw 



174 ' oBSTETEic cLrcnc. 

the patient at 4 p. m. when the os was low down in the pelvic 
cayitj, about the size of half a dollar, and still rigid. The 
liquor amnii was in excess, and the presenting part not 
recognizable. Dr. Elliot decided to rupture the membranes, 
ascertain the presentation and position, and then, if neces- 
sary, dilate with the douche or Barnes's dilators. When the 
waters were evacuated, the head of a dead child was found 
to jDresent, with the occiput to the right sacro-iliac sjnchon- 
di'osis. The largest-sized Barnes's dilator was introduced, 
and twenty measured ounces of warm water forced in, Dr. 
Studley and others being present. In five minutes the os 
was fully dilated, but when the water was allowed to escape, 
and the dilator withdrawn, the os instantly contracted down 
to two and a half inches in diameter. A warm douche was 
then directed, and given at 5 p. m., with the effect of causing 
ftdl dilatation in fifteen minutes ; and the woman was deliv- 
ered of a still-born putrid child at 6.30 p. m. The placenta 
came away in fifteen minutes, and was shown under the 
microscope to be fatty. 

In one of my cases of puerperal eclampsia, a similar fact 
was observed. 

Barnes's dilators are so valuable, that we cannot escape 
the conviction that no man is fully prepared for the contin- 
gencies which attend the induction of labor and rapid dilata- 
tion of the cervix uteri, who is unprovided with this, or a 
similar instrument. The dilatation of the cervix, by fluid 
pressure applied from below, has taken rank in midwifery as 
a fixed and trusty procedm-e, based on the closest imitation 
of Nature's laws ; and the names of Ai-not, Keillor, Jardine 
MuiTay, the younger Storer, St. Tarnier, and Barnes, are in- 
dissolubly connected therewith. But the great merit of mak- 
ing the method popular and practicable rests with Dr. Barnes, 
of London, who has the same relations to this procedure that 
Morton bears to the introduction of ether as an anaesthetic. 
It is greatly to the credit of the learned and indefatigable 



IXDrCTION OF LABOE. 175 

Dr. Barnes, that lie presents both his claims and the method 
so frankly, modestly, and completely. 

III. Sponge^ or other tents^ are valuable where the dilators 
cannot be procm-ed and in rare cases where they cannot be 
introduced and there are objections to the douche. 

The choice of means for dilating the cervix will vary 
with the degree of dilatation, and the facility with which the 
03 uteri can be reached. In extreme cases of pelvic deformi- 
ty, this latter contingency may be very important. "We 
may, however, find the cervix well down in the pelvis, the 
OS quite dilated, the head distinctly recognizable, and sus- 
ceptible of ballottement through the unruptured membranes. 
Such conditions are not infrequent in multiparas toward the 
end of gestation, and furnish the greatest facilities for the 
manoeuvi-es required. We may find great varieties of direc- 
tion of the cervix, and great differences in the calibre ; and 
we may sometimes find the cervix so dilated as to resemble 
the amniotic pouch, and yet the small dimpled os uteri 
scarcely susceptible of recognition. 

Two such cases have occurred to me. The first fell to my 
care in the Dublin Lying-in Hospital. I encouraged the 
woman to bear down strongly, and anticipated a speedy de- 
livery. This not occurring, and Dr. Shekleton visiting the 
ward, I suggested to him the advisability of rupturing the 
membranes, when he recognized the peculiarities of the case, 
and called my attention to a little dimple which represented 
the OS uteri. In that case the first commencement of dilata- 
tion was brought about by the introduction of the end of a 
small catheter. The second case occurred in my private 
practice, some years ago. My first impression, on making an 
examination, was that of gratification at the advance of the 
labor, but on searching for the rim of the cervix, I recognized 
the character of the case. The first dilatation of this os uteri 
could only be effected by the smallest-sized sponge-tent that 
we use in a contracted and unimpregnated cervix. Fearing that 



176 OBSTETRIC CLmiC. 

tliis little tent might slip within the nterine cavity, I attached 
it by a string to a body bandage. The rest of the labor was 
natnral, after dilatation had been effected. The patient was 
a multipara who had been long under treatment for chronic 
metritis, before this pregnancy, by Henry Bennett, and others. 
In a recent number of the Bichmond Medical Journal^ 
Dr. IN'ott, of Mobile, gives the formula for a paste which he 
smears OA^er sponge-tents before their introduction and which 
neutralizes their foetor. The same end is attained by Mason, 
of this city (23d Street and 8th Avenue), by the addition of 
carbolic acid to those which he prepares. Dr. Emmett has 
introduced them within the unimpregnated uterus in an India- 
rubber covering which allows the injection of water for their 
prompt dilatation, while it expands ^<2r^^fl;55w with the tent. 
It is also certain that there is no advantage in coating the 
tents with wax ; and that their action is thus delayed. 

lY. Manned dilaiaiion is serviceable where there coexists 
dilatability without dilatation — a fact only to be appreciated 
by trial. 

It is also to be resorted to in cases where the douche can- 
not be employed, and there are no tents or dilators ; and the 
records of obstetric literature present numerous examples of 
rapid and successful dilatation of an undilated and rigid os 
uteri by this means alone. Still, with the exception of these 
cases, in which there is dilatability without dilatation, manual 
dilatation should rarely be resorted to, on account of the supe- 
riority of other methods, and of the greater liability of bruising 
the cervix by this method in difficult cases. 

It is a good habit to appreciate in each case of labor whe- 
ther the cervix be dilatable or not, as was practised in the 
case of Mary Wilson ; for in many the perpetual prayer of 
women for assistance may really be answered in a simple 
and very effectual manner by this manoeuvre ; while the 
non-recognition of this fact has most undoubtedly cost the 
lives of very many mothers and children by postponing the 
time for an elective and safe operation. 



EN-DUCTION OF LABOE. 177 

How many cases liave I seen of delayed labor to wliicli 
I Lave been called, where the apparently rigid cervix could 
be stripped over the child's head in an instant, and admit 
either of a prompt spontaneons termination of the labor, or 
of immediate delivery by art ! In some the delay made the 
difference between life and death. 

Case 72. — Rigid os ; douche i manual dilatation j for- 
cejps to head transversely 2^lctced injpelmc excavation. 

McCndder ; aged 32 ; first pregnancy ; fell in labor August 
26, 1858, in Bellevne Hospital ; Dr. E. W. Lambert, House 
Physician, and Dr. Foster Swift, Senior Assistant ; presenta- 
tion E. O. P. 

This patient was seen at 6 A. m. on the 26th, when the 
OS uteri was as large as a dollar ; waters, according to her 
account, having been dribbling away for several days. Hav- 
ing remained in this condition for twelve hours, gr. xv. of 
ipecac, were given, and the warm douche applied by the 
house physician. Five hours after, no material progress 
having been made, the douche was repeated, and chloroform 
given. 

August 27th, 2 p. m. — The patient was reported to me as 
one on whom the douche had made no impression, though 
the stream had been steadily thrown against and within the 
OS uteri. On examination I found the os of the size and 
apparent rigidity described ; but on introducing my fingers, 
and forcibly dilating it, full dilatation was almost immedi- 
ately effected. 

8 p. M. — I was sent for by Dr. Swift, as the woman was 
showing symptoms of decided exhaustion, vagina becoming 
hot, and the head having simply so altered its position 
as to present its sagittal suture transversely with posterior 
fontanel! e to right ilium. The foetal heart seemed to me in- 
audible. I applied my forceps, with one blade over the left 
temple of the child, and the other behind the right ear, and 
12 



178 OBSTETRIC CLINIC. 

rotating the occiput under tlie pubis, delivered a dead male 
cMld, weigliing six and a half pounds, having the cord twice 
around the neck. Woman did well. 

Dr. Benjamin Lee, when House Physician of Bellevue 
Hospital, asked my advice regarding a rigid os, where he had 
been using the douche ineifectually, as he thought. On 
separating it with my fingers, I immediately stripped the 
cervix over the head of the child, without difficulty. 

Dr. John C. Draper, formerly House Physician, sent for 
me in the night to a young primipara, in labor illegitimately, 
in whom the os had resisted the douche and belladonna oint- 
ment. It was described to me as hard, diy, and unyielding 
as steel. And so, indeed, did it appear to me ; but, on intro- 
ducing my fingers within its rim, in an instant I procured 
full and complete dilatation, when Dr. Draper successfully 
delivered her with forceps. Mother and child made a good 
recovery. 

Methods for inditdng titer ine contractions . — Before de- 
ciding on the induction of labor in any case, the question arises 
as to the influence that we can bring to bear in developing 
the uterine contractions themselves ; and we must admit the 
uncertainty of our reply. These cases may all be divided 
into two great classes : 1. Those in which the danger to 
mother or child, or both, is so deadly that we would not hesi- 
tate to deliver by the hand or by instruments, so soon as the 
cervix were sufficiently dilatable for the task. 2. Those in 
which the necessity is not more pressing than in the ordinary 
conduct of a labor which had fortunately occurred prema- 
tm-ely at the most favorable time. 

In the first category of cases, our duty being very plain 
and clear, we ask only that the os be sufficiently dilatable, 
and with the douche and Barnes's dilators, we can as a law 
speak confidently of terminating the labor within a few 
hours and, perhaps within two. Still we must be prepared for 
disappointment even in these cases; while in the second 



rNTDUCTION OF LABOR. 179 

category Tre may have to dance attendance, to tlie fatigue 
and disappointment not only of tlie patient, bnt of ourselves, 
and all concerned. 

One of the surest signs of inexperience in these latter 
cases is the confidence with which a man may speak of the 
certain results to follow interference within a given time ; 
and those most given to these prophecies are those who have 
had good luck in an experience of one or two cases. 

It is as good a rule to give a guarded prognosis as to time 
in these as in all cases of labor. No patient regrets that the 
affair should be over sooner than was anticipated ; but the 
courage and hope which have sustained the laboring woman 
nobly to the appointed hour, may fail her when this is past ; 
and what can the physician say, except that either something 
unforeseen (and necessarily untoward) has happened — an 
alarming fact — or that he was mistaken in an opinion which it 
was not necessary for him to give ? It is better as a rule to say 
that one cannot tell ; but with some very nervous patients the 
best progjiosis as to time is veiled in oracular obscurity, and 
susceptible of more than one interpretation. " It might," 
and " it may," and " if." Still, as the old Scotchman said to 
his son, " Honesty is the best policy ; I have tried baith." 

The following case offers a marked example of the differ- 
ence between procuring full dilatation of the cervix uteri and 
inducing persistent uterine contractions : 

Case Y3. — Deformed pelvis / premature labor / tmusual 
and Quarhed difficulties in the induction ; forceps hy Dr. 
Taylor 'j msico-vaginal fistula in a previous labor. 

In the New Yorh Journal of Medicine^ September, 
1858, 1 have published, in an article on Operative Midwifery, 
Case 21, the history of this patient's first labor, which I saw 
in consultation with Dr. H. S. Hewit, and Prof. John T. 
Metcalfe. In that labor the child presented the breech, and 
was delivered with the perforator and crotchet. We then 



180 OBSTETRIC CLINIC. 

made out tlie entire brim to be imdersized, witli aj^parently 
2f inclies of antero-posterior diameter of brim and a sharp 
promontory. Subsequent examination lias satisfied me that 
the conjugate diameter does not exceed tbree inclies. Pre- 
mature labor was strongly recommended to tlie patient after 
that delivery in the eyent of subsequent impregnation. This 
opinion was disregarded, and she sought other adyice. After 
a yery long and tedious labor at term, she gaye birth, with- 
out operative assistance, to a second child, which was still- 
born. It was reported to me that great moulding of the head 
occurred in this labor, and a vesico-vaginal fistula, resulting 
from the long-continued pressure of the head, forced the pa- 
tient once more to Dr. He wit for relief, which was most 
kindly extended. The fistula required a number of opera- 
tions, performed according to Sim's method, and was at last 
permanently cured. 

Pregnant lor a third time, she applied to me, by Dr. 
Hewit's advice, for admission into Belle vue Hospital, where 
I determined to bring on the labor at about the end of the 
seventh month. Her general health was good, vagina per- 
fectly sound, urine normal. As some puerperal fever just 
then showed itself, I placed her in a separate ward with a 
special attendant, and requested Dr. Maus R. Yedder, then 
one of my house physicians, to take charge of her, and carry 
out the treatment which I directed. Severe illness of one of 
my children interposed some delay in the management of the 
case, and forced me to leave town on the day of the delivery, 
which was accomplished by my colleague. Prof. I. E. Taylor, 
but the post-mortem of the child was directed by myself. 

The following memoranda are those of my friend Dr. 
Yedder. It is necessary, however, to state, that on Tuesday, 
October 15, 1861, at about the time fixed for induction of the 
labor, the patient was ascending a stairway when the mem- 
branes ruptured spontaneously, though no very great amount 
of liquor amnii escaped. 

^' On making a vaginal examination, the os and cervix 



mcrcTioN OF laboe. 181 

uteri vrere found soft aud sliglitlj dilated, while the vagina 
was plentifully lubricated with mucus. Labor-like pains 
occurred at irregular intervals until Wednesday morning. 

" On Thursday, ITth, 11.30 p. m.. Dr. Elliot ordered a 
warm uterine douche. The patient being placed on her 
back, the nates projecting oyer the edge of the bed, an ordi- 
nary gutta-percha enema syringe was used to inject the 
water. With two fingers introduced into the vagina, I di- 
rected the orifice of the pipe directly into the interior of the 
cervix, and gradually injected about two gallons of warm 
water. This proceeding appeared to have the desired efiect, 
as uterine contractions took place almost immediately, and 
the OS uteri became softer and more expanded. 

" On Friday morning (18th), I ascertained that the pains 
had occurred during the night at intervals, but had ceased 
entirely toward morning. An examination per vaginam 
being made, the os uteri was found almost entirely closed. 
The douche was repeated and followed by the same efiect. 
The pains ceased during the afternoon, and in the evening a 
vaginal examination revealed that the os had returned to its 
former condition, 

" Saturday, 19th, 8.30 a. m. — The patient slept well, has 
no pains, and her bowels have moved. Eepeated the injec- 
tion. The OS dilated to about the size of a dollar, but ute- 
rine contractions did not supervene. 

^''Monday, 21^ 8.30 a. m. — Patient in good condition. 
Repeated the hot douche, which was again followed by the 
same results. 

'' Tuesday, ^2d, 8i30 a. m. — Patient has not slept well, is 
irritably nervous and hysterical, and complains of rigors. 

" Wednesday, 236?, 7.30 p. m. — Patient in good condition. 
Dr. Elliot found the os slightly dilated, and determined to 
introduce a large-sized sponge-tent, which was allowed to re- 
main for twelve hours. On removing the tent, the next 
morning, the os was found fully dilated, though but few ute- 
rine contractions had occurred during the night. In short. 



182 OBSTETRIC CLINIC. 

both the douche and the sponge-tent dilated the cervix to 
such an extent as to prepare it fully for labor, but no pains 
supervening, the relaxation wonld pass off and the os regain 
its normal condition. Galvanism was now suggested to ex- 
cite nterine contractions, and was accordingly used. One 
23ole was applied so as to pass along the spinal column, and 
the other was placed upon the abdomen and into the vagina 
alternately. This treatment was repeated several times dm-- 
ing the day, occasionally producing uterine contractions, yet 
without having the desired effect. 

" Friday^ 2^th, 12 m. — Being disappointed with the effi- 
cacy of the nterine douche, sponge-tent, galvanism, etc.. Dr. 
Elliot prepared a part of an elastic male catheter (Ko. 8), 
three and a half inches long, with a string attached to facili- 
tate its removal. He then introduced this catheter anteriorly 
between the uterus and the membranes, and allowed it to re- 
main for fifteen honrs. 

" Uterine contractions continue to occur at long intervals 
until Sunday, 27th, 5 p. m., when strong frequent and labor- 
like pains supervened, the os uteri was dilatable, and did not 
oppose any obstacle to the labor. 

" At 10 p. M. the OS was fully dilated, and the head pa^ed 
into the excavation. 

''Dr. Taylor being sent for during the absence of Dr. 
Elliot, concluded, both from the deformity of the pelvis, and 
the strong uterine contractions, as well as the non-advance- 
ment of the head, to apply the forceps, which was accord- 
ingly done. 

" The child was delivered by gentle traction and without 
difficulty, while the placenta followed almost immediately. 
The child gasped a few times, and, by placing the ear to its 
chest, the heart was ascertained to be beating. 

" Every effort was made to resuscitate the child, but in 
vain. Mother recovered perfectly." 

Post-mortem apjpearances twelve hours after delivery. — 
Male child ; weight, six pounds two ounces ; length, nineteen 



INDTJCTIOX OF LABOE. 183 

and a half inclies ; cii'cnmfereuce of head, just above the ears, 
twelve inches. The child vras apparently well formed and 
well nourished ; nails distinct and well developed. Trace of 
forceps on right brow between anterior frontal angle and 
right ear ; trace of the other blade posterior to left ear about 
half an inch below the tip of mastoid process ; head well os- 
sified ; frontal suture distinct to frontal superciliary ridge ; 
left side depressed below the right to a marked extent ; left 
fronto-parietal suture somewhat obscured at its lower part by 
oedema, but for the upper two-thirds the seat of an obvious 
depression, in breadth corresponding to that of the fore-finger. 
This depression is formed by the frontal and parietal bones, 
but the parietal bone is depressed below the margin of the 
frontal. This parietal bone is also depressed at the parietal 
sutm-e below the right parietal bone. The caput succeda- 
neum is principally situated at the posterior and superior 
part of the right parietal bone. Lips blue black ; some post- 
mortem discoloration of cheek and upper lip. On removing 
the scalp the relative situations of the bone described became 
more evident, and the depression of the anterior part of the 
left parietal bone more distinct. On removing the cal- 
varium an amount of fluid blood escaped, from six drachms 
to an ounce. The brain presented an ordinary amount of 
vascularity, with no effusion. On removing and slicing the 
brain no clots nor extravasated blood could be detected. 
Weight of brain, twelve ounces. Lungs have been inflated, 
crepitating under pressure. Other viscera appeared to be 
healthy. Bladder moderately distended with urine. 

Remarlcs. — It thus appears that spontaneous rupture of 
membranes and escape of some liquor amnii, with labor-pains 
supervening — dilatation of cervix uteri by douche, as far as 
is generally necessary for induction of true labor-pains — full 
dilatation of cervix by sponge-tent, and galvanism, had all 
failed; when after leaving within the uterus (between that 
organ and the membranes) three inches and a half of a ^No. 
8 elastic male catheter for fifteen hours, sluggish, and reluc- 



184: OBSTETEIC CLEN'IC. 

tant uterine contractions gradually acquired force sufficient 
to drive the head through the contracted brim, when the 
labor was terminated by Dr. Taylor. 

For a correct appreciation of the case, it is important to 
understand that after the douche, as after the sponge-tent, 
the cervix uteri and vagina were sufficiently prepared for the 
labor, though the uterine contractions persistently refused to 
obey our 'summons, and press the head upon the cervix. 
The preparations were sufficient, but the labor would not be 
provoked. Descent of the head was not prevented by the 
deformity, but by the lack of true labor-pains. How often 
do we see such cases in natm^al labor among multiparse, 
where the os is widely open and pains supervene, while the 
finger readily touches the head, floating in the liquor amnii, 
and after all the pains may cease, and the patient's labor not 
occur for a fortnight ! Those eases where there is a con- 
tinuous drain of liquor amnii through the rent membranes 
continuing for weeks, without labor, come within the same 
category. I published a remarkable one in the New York 
Medical Press ^ for I^ovember 4, 1859, where, with the ap- 
proval of Dr. Barker, I induced labor after the watei^ had 
thus steadily dribbled for seven weeks. It is interesting to 
observe the effects of pressure by the projecting promontory 
on the foetal head, and to see how the caput succedaneum, 
the depression, and marks of forceps all agree in determining 
the character of the presentation. In my experience, the 
difficulties signalized in this case are entirely exceptional, 
though, as an exception, it may serve to prove the rule that 
the induction of premature labor is an excessively simple and 
certain measure. I regret that my memoranda of the date of 
the last menstrual period before impregnation are lost. 

The following history details the first labor of this patient, 
and offers an example of the difficulties which may compli- 
cate an original peMc presentation, in a contracted pelvis. 

She has since been successfully delivered of a living child 
of small size,' by forceps, in a fourth labor. 



INDrCTION OF LABOE. 185 

Case Tl. — Deformed jpelvis ; Ireech presentation ^ perfora- 
tor j convulsions; recovery. 

Mrs. , a primipara, aged 25, short in stature, but 

Tvith no apparent deformity, came to full term, and fell in 
labor on tbe night of the 12th, under the care of my friend, 
Dr. H. S. Hewit, At 11 p. m. the membranes had ruptured 
and the waters escaped. Foetal heart beating ; breech pres- 
entation recognized ; pains slight. Sent for me at 9 a. m., 
13th. Found os fully dilatable; sacrum of child directed 
to left sacro-iliac synchondrosis. Foetal heart very audible, 
with summrnn of intensity above and to left of umbilicus ; 
maternal passages and pulse good. Pains had been strength- 
ened by ergot. Recognized general pelvic deformity ; pubic 
arch good, but rami of ischia too close. Entire brim under 
size, with apparently 2f of antero-posterior diameter and 
promontory sharp. 

The pains continued good all day, as did the foetal heart 
and the mother's condition. The child's scrotum was dis- 
tended and forced down. Its sphincter ani contracted around 
the finger. 

In the evening, after watching the patient for twelve 
hours, I advised an operation, and stated that the difficulty 
would be so great that I should require another assistant, as 
Dr. He wit was to take charge of the chloroform. Dr. Met- 
calfe then became associated with us, and I proceeded with 
a blunt hook to bring down both thighs, and then both arms, 
which was accomplished without fracture. The head came 
to the brim with the chin to the left ilium, and no manual 
efforts were of any avail ; nor was there any space for for- 
ceps. I then introduced the blunt hook into the mouth, the 
child being dead, and pressing the crotchet against the occi- 
put, worked till I fractured the jaw at the junction of the 
left ascending ramus, without any effect. Then introduced 
the perforator behind the mastoid process of the right side, 
and made ineffectual efforts with the crotchet. At this stage, 



186 OBSTETRIC CLINIC. 

tliere was room for one blade of the ceplialotribe in front of 
the left sacro-iliac synchondrosis, and I introduced it in the 
hope that some lucky move would make room for the other ; 
but it was impossible. Accordingly I reintroduced the per- 
forator and crotchet, and pulled till I was temporarily ex- 
hausted, though the head had now begun to descend. Dr. 
Metcalfe succeeded me, and with strong effort withdrew the 
head. Placenta followed immediately, and uterus contracted 
well. K'o hemorrhage. Some symptoms of metritis, which 
subsequently presented themselves, yielded to a blister dressed 
with mercurial ointment, and the exhibition of morphia and 
the veratrum viride. 

The patient had convulsions of a mild character on the 
following Tuesday night, in which the tongue was not bitten ; 
and again on Wednesday night. Dr. Hewit being summoned 
suddenly to her, witnessed a recmTcnce of the phenomena 
apparently . from fright. Urine drawn with the catheter, 
and examined by Dr. Gouley, gave evidence of a slight 
amount of albumen with casts of the uriniferous tubes, and 
blood-corpuscles. 

26^A. — Has done well. Prematui-e labor advised here- 
after. 

The most reliable methods for inducing uterine contrac- 
tions when premature labor is decided upon, and the pains 
do not follow dilatation of the cervix, are mechanical ; but 
they are all liable to demand many hom'S of valuable time. 

Y. The introduction of a catheter 'between the memhranes 
and the uterus is justifiable whenever all other conditions for 
delivery are favorable, and where the contractions of the 
uterus have been wanting, imperfect, or sluggish. Although 
theoretically a harsh procedm^e, it does not appear to increase 
risks of metritis ; and is very effectual when left in situ. A 
renewal of the trials of very flexible materials which have 
been used in the history of the operation, will probably be 
advantageous. 



INDUCTION OF LABOE. 187 

Eodenberg recommends tlie introduction within the 
cervix of a bongie promptly withdrawn, and frequently re- 
introduced. He points to fifteen cases, in fourteen of which 
the children were born alive ; and when the youngest of that ^ 

number had reached the age of two years, seven of them \ 

were known to be alive. 

Zuydhoek recommends the introduction of a wax bougie, 
two or three lines in diameter, between the anterior wall of 
the uterus and the membranes, and leaving it there for a 
length of time — a method preferred by Dr. Lehman, of Am- 
sterdam. 

I generally select a piece of a IN^o. 8 gum-elastic flexible 
male catheter, and attach a string tightly to the cut end, so 
as to faciKtate its withdrawal in the event of its slipping 
vrithin the uterus ; but this contingency has never occurred 
•in my practice, and on the contrary the instrument has 
more than once slipped out of the uterus into the vagina, 
and thus time has been lost. 

Case 76. — Induction of Iccbor with douche, dilators, and 
catheter. — Two children had leen previously delivered after 
^perforation. 

Labor induced for deformity of the brim in the Lying-in 
Asylum, with the assistance of Dr. Sterling, Resident Physi- 
cian, June 8, 1865. 10|- p. m. — A tepid douche for twenty 
minutes. 9th, 8 a. m. — Os uteri sensibly dilated. Bowels 
being constipated, enema ordered, which produced two 
movements. 9j- a. m. — Second douche. 12J p. m. — Os di- 
latable to nearly the size of a Mexican dollar. Barnes's di- 
lator, IS'o. 2, was introduced and injected until she began to 
complain of pain. Cranial presentation previously recog- 
nized. 2f p. M. — Dilator readily removed ; cervix still long, 
well dilatable ; membranes distinct and distended. 3J p. m. 
— Largest-sized dilator introduced, and distended fully with- 
out complaint. 9 p. m. — Dilator removed by the hand. A 



188 OBSTETEIC CLINIC. 

trace of albumen detected in nrine drawn with the catheter. 
There have been pains, which have ceased entirely. They 
returned under digital examination, and becoming pretty 
fah, and the membranes commencing to pass well down the 
cervix, we decided not to introduce the dilator. 

IQth^ 12f A. M. — The pains have again markedly dimin- 
ished, but return when the digital examination is made. I 
then introduced a piece of a ]^o. 8 flexible male catheter be- 
tween the membranes and the uterus, in front of the right 
sacro-iiiac synchondrosis, and left it there. 6 a. m. — The 
pains have again subsided ; but they had come on with suffi- 
cient violence to prevent the patient from sleeping. The 
catheter was in the vagina, and I replaced it anteriorly. 
Heretofore the presentation had been recognized as left occip- 
ito-anterior. At this visit the convexity of the dorsal curve 
was recognized by abdominal palpation to have changed 
to the right side, and the summum of intensity of foetal 
heart-sounds had also changed. 11|- A. m. — Fains have 
been moderately good ; catheter m situ ; membranes on a 
level with the os externum, in the intervals of a pain. 

llth^ 12-|- A. M. — Almost continuous pain ; catheter with- 
drawn, and not replaced. Toward morning some chloro- 
form given in moderate quantities for relief from the force 
of the pains. 8| a. m. — Membranes which have touched the 
floor of the pelvis have been allowed to rupture spontaneous- 
ly. I aided the entrance of the head through the contracted 
brim by pressure from above with some success. 

11 J A. M. — Child born with three coils of funis very tight- 
ly around its neck, and very feeble. Dr. Sterling's care 
soon revived it; and the child, a vigorous boy, has since 
done well, without a single unfavorable symptom, as has the 
mother. 

The following measurements were made immediately 
after birth. Conjugate diameter^ three inches and three- 
eighths. Placenta^ two and a half pounds in weight, width 
nine inches, thickness two inches. Cord^ length forty-two 



INDTJCTION OF LABOE. 189 

and a half inches. Child, weight nine ponnds, length twen- 
tv-thi-ee inches. Chest, twentj-three inches around. Head. 
Bi-mastoid diameter three inches and one-eighth. Bi-parietal 
three inches and five-sixteenths, measured from a point taken 
at the temporo-parietal snture in a line with the upper border 
of the fronto-parietal sutm-e. Occipito-mental fourteen inches 
and a half in circumference. Sub-occipito bregmatic twelve 
and three-eighths. Sub-occipito frontal thirteen and a qua]-- 
ter. Largest circumference of head over the parietal bones 
fourteen and one-eighth of an inch. Her previous children 
are reported to liave been very large. 

Case T6. — Induction of labor with douche, dilators, and 
catheter. 

Mrs. , seen in consultation with Prof. Sajre, October 

6, 1862, in consequence of the fact that in the previous preg- 
nancy the child had been delivered after perforation. As she 
was restless, she was brought under chloroform, when I meas- 
ured the conjugate diameter with Lumley Earle's instrument, 
and estimated it at four inches. The transverse seemed to 
be about equal. The linea ileo-pectinea from the right ilium 
to the pubis straighter than it should be, and straighter 
than the other side. !N'othing abnormal but a transverse 
diameter of brim somewhat diminished, and also the ob- 
lique diameter from the right acetabulum to the left sacro- 
iliac synchondrosis. Room enough for an average-sized 
child to pass at term, especially in a left occipi to-anterior 
position. The foetal heart was beating to the left in cor- 
respondence with the dorsal curve, at 120 to the minute. 
Probabilities of its being a male suggested to the patient. 
Cervix well-shaped and well-directed. Head presentation 
recognized by conjoined manipulation. October ^4zth. — 
Measurements repeated. She had been last unwell Feb- 
ruary 14:, 1861. Quickened July 5th to 10th. Induction 
of labor decided on for l^ovember 28th. First douche 11 
p. M. ; after which smallest-sized Barnes's dilator introduced. 



190 OBSTETEIC CLmiC. 

It soon slipped out, and she slept well during the night. 
29^A. — Can introduce two fingers in the os. Second douche 
at 11 A. M., and then introduced the second-sized dilator, and 
distended it as much as she conld bear. 1 p. m. — The dilator 
sh23ped ont in three-quarters of an honr. Pains have com- 
menced. Os more dilated, not dilatable. Third donche. 
Membranes passing within the cervix near the os. On the 
right side of the head, within the membranes, I conld touch a 
hand, w^hich moved rapidl j away from the examining finger. 
Pnshed it np as far as possible, and then sought to press the 
head further in the brim, with the hand over the abdominal 
wall. Quiet and nourishment. 4 p. m. — Fonrth donche. 
Pains about every fifteen minntes. Piece of 'No. 8 elastic 
catheter on the left side, within the cervix. This was ex- 
pelled by vomiting, and replaced. Noveinber SOth, 9 A. m. 
— Catheter has been expelled. More dilatability. Hand 
not recognizable. Slept vrell. Pains every half-honr or so. 
Largest-sized dilator introduced, and when expelled, in three- 
qnarters of an hour, fifth douche given, and then reintroduced 
catheter. 4.30 p. m. — Pains very good. Catheter snngly i?i 
situ. Withdrawn. The pains increased with the greatest 
force and frequency, giving scarcely a moment's respite. 
Chloroform begged for and refused. At ll^- p. m. a healthy, 
lively male child, weighing seven pounds, was born, which 
did well, as did the mother. 

Hemarlts. — Perhaps this theory, which has occurred to me, 
may suggest one impediment in the first labor. After that 
delivery, she had great hardness, swelling, and then fiuctna- 
tion in the right iliac region. An opening was made there, and 
a counter-opening became necessary in the vagina. A free 
discharge took place, some of which resembled honey ; and 
finally, under iodme injections, the sinus closed. Is"ow, it is 
possible that a small ovarian, or parovarian tumor, may have 
accidentally diminished the contracted transverse diameter. 
May not this have become inflamed, and may not its con- 
tents have escaped with the results of peri-ovaritis? At 



INDUCTION OF LABOE. 191 

the time wlien I examined tlie case, no trace remained of all 
these serions post-partnm conditions bnt the large scar in the 
abdomen. 'No^v, while, of conrse, the history of this previous 
inflammation lent additional force to the arguments for in- 
ducing premature labor, the great question turned, after all, 
on the accurate measurement of the pelvic diameters ; and 
the decision first to postpone the operation until a late period 
of pregnancy, and, secondly, of inducing it at all, was based 
on its result. Still, as I have stated, this woman may yet 
give birth to living children at term. 

YI. The memhranes may he separated with advantage 
when the cervix is commencing to dilate satisfactorily, if 
this does not involve too great a risk of premature rupture ; 
as the early descent of the membranes, in a favorable presen- 
tation, facilitates the phenomena of natural labor. 

YII. The electriG and galvanio currents demand further 
trial, and may yet enable us to dispense with other means of 
inviting uterine contractions, notwithstanding the discourage- 
ments which have so often attended their use. 

Still, up to this time, I have had no satisfaction from 
these agents in the very few cases in which I have employed 
them for this purpose. And they have failed me in cases of 
amenorrhoea, and as a galactogogue. It seems to me that there 
is too great a tendency in medical journals to parade a few 
cases in which the menses, or the secretion of milk, followed 
the use of the current, rather than to examine the question 
dispassionately, and on a large scale. I have made careful 
trials, with Kidder's best instrument, on hospital patients 
observed by the class, without success, and I have used the 
same instrument very thoroughly and very often in private 
practice without other satisfaction than that of having made 
the effort. Even in the cases adduced by the best authori- 
ties the number is too few to enable us to feel certain that 
coincidences are not reported as results. 



192 OBSTETRIC CLIN-IC. 

In a case of amenorrlioea in mj wards in the winter of 
1866, where the constitution of the patient, and the state of 
the nterine organs, gave every reason for believing that only 
a slight impulse was needed to bring on the flow, Kidder's 
best instrument was used in the most thorough manner, with 
Hammond's instrument for conveying the cm-rent to the 
cervix uteri, and in every other way, but with no effect. 
Before the next period the patient reentered the hospital in 
the service of my colleague. Prof. Taylor, who examined 
carefully into the situation, and used the sound, among 
other methods of exploration, as I had done before. Before 
the next day the flow had been established without any elec- 
tric current. Moreover, in some cases of menstrual epilepsy 
which have given me great anxiety, and when the plethoric 
character of the patient and the scanty menstrual flow pre- 
eminently indicated emenagogue remedies, electricity has 
utterly failed me, though thoroughly applied, at recurring 
periods, both to the uterus and to other parts of the body. 

This experience does not prevent me from still resorting 
to these agents, and from hoping better results. But with 
this experience one may question whether a large proportion 
of the successful results recorded may not have been coinci- 
dences, or due to other causes. 

In " Yanity Fair " Thackeray has most delicately sati- 
rized the liability of om' profession to a mistaken appreciation 
of the efl'ect of our remedies : 

Major Dobbin was retm-ning home invalided from India, 
wretched in mind from the conviction that Amelia was mar- 
ried, when he unexpectedly learned from Jos. Sedley that 
such was not the case, and he instantly began to mend just 
as the puzzled doctor had changed his prescription. 

'*• The ship-sm-geon congratulated himself on the treat- 
ment adopted by him toward his new patieut, who had been 
consigned to ship-board by the Madras practitioner with 
very small hopes indeed, — for from that day, the very day 
that he changed the di-aught. Major Dobbin began to mend." 



IXDUCTION OF LABOE. 193 

YIII. Puncture of the menibranes is to be avoided in all 
cases wliere tlie danger to tlie mother does not point to this 
procedure, as may happen in placenta prsevia, and over- 
distension of the abdomen ; or where the labor can not be 
promptly completed. 

There are few rules more worthy of being impressed on 
the mind of the young obstetrician than the desirabihty of 
preserving the integrity of the membranes until the cervix 
uteri is fully dilated or dilatable ; and until both the position 
of the child and its relations to the maternal organs are such 
as to promise a natural or permit a speedy delivery. So 
long as the membranes are intact, so long do the relations 
of the foetus to the mother continue unchanged, and while 
there may be fatigue and even exhaustion, the maternal tis- 
sues are rarely subjected to unnatural pressure, or the child's 
life endangered by the phenomena of labor. But from the 
time when the waters are evacuated, all this is changed, and 
delay in the progress of the labor is an element of danger to 
both lives. The expert is better fitted to decide on this 
manoeuvre at an early period of the labor, since his clinical 
tact enables him to exclude the presence of causes of delay 
which might well exist, and be overlooked by the be- 
ginner. 

"While, however, we occasionally meet with cases in which 
the waters are spontaneously evacuated, and may continue 
to dribble for one, two, or even three months, without induc- 
ing uterine contractions, and without predisposing the cervix 
to rigidity during the labor, it is a law that uterine contrac- 
tions generally supervene upon even the partial escape of the 
waters ; and that their premature discharge is very apt to be 
followed by a tedious labor, and a rigid os, with increased 
risk to mother and child. 

Still, the danger to foetal life in labor, induced by this 

method, is not always as great as we might anticipate, since 

Hoffmann has recorded one hundred and eighty-three cases 

of labor induced in this manner, with one hundred and three 

13 



194: OBSTETEIO CLINIC. 

living cliildren. Yet, to diminisli the risk to fcetal life, 
Meissner, of Leipsic, preferred to puncture the membranes 
with a stiletto at some distance from the os, and allow but a 
small quantity of the water to escape. 

IX. Medicines are not specially indicated for the induction 
of premature labor. Theii' use is to be formulated on other 
considerations. 

Ergot is too uncertain in cases where uterine contractions 
have not commenced ; when efficient, it increases the risk to 
the child. As an agent for strengthening existing contrac- 
tions, and rendering them more frequent, its claims are para- 
mount. Still, with the exception of those cases, in which 
flooding may be apprehended ; and those in which the delay 
can be attributed to no other cause than deficient expulsive 
force, while the head or breech is yet very high in the 
pelvis ; or of those in which the vagina and perineum are 
so rigid as to be specially liable to laceration from instru- 
ments — in those cases of delayed labor, in short, in which 
the forceps can readily be used, and the choice lies between 
them and ergot, my personal preference would be for the 
forceps ; though my long observation of the use of forceps in 
inexperienced hands would incline me to recommend the use 
of ergot to the beginner.* 

In many cases in which this election has had to be made, 
ergot has given me the greatest and promptest satisfaction. In 
others I have administered large doses ineffectually (in one 
case 5 jss of Squibb's fluid extract of ergot and 3 yj of [N'eer- 
gaard's saturated tincture), and have been obliged to deliver 
with forceps after all. And, again, the ergot has acted de- 
lightfully and with great power, but has afterward proved a 
serious obstacle to the removal of an adherent placenta — a 
condition which can never be diagnosticated in advance. If 

* A very valuable paper on the choice between ergot and forceps, by my 
colleague, Prof. Fordyce Barker, is to be found in the Transactions of the New 
York State Medical Society for 1858, 



INDUCTION OF LABOR. 195 

the effects of ergot be desired, tlie doses must be frequently 
repeated if ineffectual. 

The follo-^ing cases illustrate the risks from reliance on 
ergotj as well as the compatibility of the most violent and 
continued uterine contractions induced by this drug, with 
the continuance of the foetal heart : 

Case 77. — Tedious labor ; ergot ^ forceps. 

Mary Collin, aged 21, primipara, January, 1861. Dura- 
tion of labor fifty-six hours. Still-born male child, weighing 
eight and a half pounds. L. O. P. Dr. Page, House Physi- 
cian, Bellevue. Eight hours before terminating the delivery 
I advised ergot (vagina cool and moist, foetal heart beating), 
as there had been no advance for many hours. Under its 
use marked progress was made, and at half-past one, as there 
appeared a good likelihood that the delivery would be ter- 
minated without instrumental interference, I decided to wait a 
few hours longer. At half-past four there was no foetal heart, 
and the vaginal discharges were offensive, and of an olive 
green color, while no further advance had been made. The 
cause of the delay was not clear to me, but it is certain that 
the vagina was unusually small and relaxed. The forceps 
being indicated, I delivered, in presence of the house staff, 
having to perform rotation and extension, and derived great 
assistance from examining the posterior vaginal wall through 
the rectum, as the risks of laceration were very great. Four- 
chette slightly lacerated. Chloroform. Child still-born. 
Mother did well. 

Case 78. — Deformed pelvis / ergot / forceps. 

Rose Keenan, aged 22, primipara. Head presentation ; 
first position; duration seventy-two hours; female child; 
born alive, but did not survive ; weight seven pounds eight 
ounces. 



196 OBSTETRIC CLINIC. 

In her childhood this patient dislocated the right femur 
on the dorsum of the ilium, and reduction was never effected. 
The true pelvis was unaffected except in the outlet, where 
the corresponding rami of the puhes and ischium were 
straighter than natural, and interposed a firm barrier to de- 
livery. Twelve hours before delivery I gave a fiill dose of 
ergot, and intended to call during the night to see the re- 
sult. But I was not called, and did not awaken until morn- 
ing, when the nurse informed me that the pains had been so 
continuous and severe as to drive Rosa from her bed, and 
cause her to roll on the floor in agony. Foetal heart unaf- 
fected. 'No progress. She was in the Lying-in Asylum, 
and I sent for Drs. Cheesman and Metcalfe, who arrived, 
and decided to deliver with forceps. I could not introduce 
the second blade, and Dr. Cheesman carried it successfully 
to its position by at once placing it behmd the right acetabu- 
lum. The deformity had prevented me from giving it the 
accustomed spiral sweep required from the fact that rotation 
had not been effected. The child was delivered with diffi- 
culty alive, but did not smwive. This lesson, which I then 
learned (June 28, 1852), has been of service to me in a num- 
ber of cases since that time. No chloroform given. Mother 
did well. 



» 



CHAPTEE YII. 

EFFECT OF THE TOKEC CrRCTJLAE CONTEACTION OF A BAISTD OF 

TTEEmE IVnJSCFLAE FIBEES OK LABOR. ^BROW AKD FACE 

PRESENTATIONS. RUPTURE OF UTERUS. 

Effect of the tonic circular contraction of a band of uterine muscular fibres on 
labor. — Case: Brow presentation; chloroform, forceps, version, the per- 
forator, crotchet, and craniotomy forceps having failed to overcome this 
obstacle, the patient was delivered with the cephalotribe. — Case: Brow and 
face presentation ; powerless labor with circular band of contracted uterine 
fibres; chloroform; lever; forceps; partial version; perforator. — Case: 
Contracted conjugate ; tonic circular contraction of uterine fibres ; failure 
of forceps, twice applied after an interval of three hours ; chloroform ; im- 
possibility of version; craniotomy. — Case: Forceps; tendinous band in 
vagina; peritonitis. — Kemarks on brow and face presentations. — Case: 
Forehead presentation converted by conjoined manipulation into that of the 
vertex. — Case: Kupture of uterus; presentation of brow, hand, and funis; 
delivery by version and crotchet; recovery of mother. — Case: Rupture of 
uterus; version; brow presentation; anterior uterine obliquity. — Case: 
Rupture of uterus; patient died before delivery. — Further remarks on brow 
presentations. — Case: Right mento-ihao presentation; death of child, and 
then craniotomy. — Case: Shoulder and arm presentation; cephalic version 
by external manipulation, aided by vectis and forceps, ineffectual to flex the 
head ; podalic version and perforator. — Management of frank face presenta- 
tions. — Case: Locked face presentation; effect of manipulation; forceps; 
perforator. — Anecdote efface presentation. — Chin posteriorly. — Case: Face 
presentation; chin to right sacro-iliac synchondrosis; rotation of chin to 
pubes with forceps. — Further illustrations of the uses of the hand in facili- 
tating labor. — Case: Twins in a pelvis with conjugate of three and a half 
inches; risk of locking of heads prevented by manipulation. — Benj. Pugh's 
recommendations in the delivery of the head in breech presentations. 

TVeile, as a law, if the child be properly proportioned to 
a normal pelvis, and properly presented, delay in the labor 
will generally depend upon inefficient nterine contractions, 



ill 



198 OBSTETRIC CLINIC. 

or rigidity of the cervix uteri or soft parts, there are occa- 
sional examples of delayed labor from tonic contractions of a 
band of the nterine mnscular fibres themselves. An irregular 
tetanic uterine cramp of certain fibres, which may not in- 
terfere with the due recurrence of the pains, but which op- 
poses an unyielding and irresistible barrier to their efiects on 
the advance of the child. It is probable that many of these 
cases are not appreciated, and that they are more frequent 
than is generally supposed. The following histories offer 
illustrations of the difficulties which result in practice. 

Case 79. — Brow jpresentation ; forceps and version 
failed in consequence of the ^powerful unyielding contraction 
of a circula/r land of uterine muscular fibres / perforator, 
crotchet, and craniotomy forceps having also failed, the 
patient was finally delivered with the cephalotrihe / chloro- 
form, 

Mrs. fell in labor with her fourth child in the night 

of the 6th of March, 1862, under the care of Drs. Bishop and 
Case. She was robust and well built, but the antero-poste- 
rior diameter of the brim was somewhat undersized, and her 
previous labors had been slow on this account, but had ter- 
minated successfully both to mother and child without inter- 
ference. Dr. Case informed me, when he came for me, that 
Dr. Bishop had failed to deliver either by version or forceps, 
and being thoroughly acquainted with his great ability in 
obstetric operations, I took my cephalotribe with the other 
instruments. By the time of my arrival, March 8th, the 
waters had been discharged for more than twelve hours. 
The brow presented, with chin directed to the right sacro- 
iliac synchondrosis; os fully dilated; child evidently full 
size. ]N^o advance had been made through the brim, nor 
was there any arrest by any portion of the pelvic brim ; on 
the contrary, flexion could be very readily brought about, and 
the presentation converted into that of the vertex. When 
this had been accomplished, the posterior fontanelle was di- 



TOXIC CIECTJLAK CONTEACTION OF UTERINE FIBEES. 199 

reeled to the middle of the left ilium, and my forceps were 
readily applied by passing the fii'st blade in front of the left 
sae.-il. sjn., and carrjdng the other directly to its place be- 
hind the right acetabnlnm. But my strongest tractions 
failed to do more than reproduce the brow presentation. A 
repetition of the manoeuvre had the same effect. In short, 
the head would turn as it were on a pivot, but not advance 
in its totality. One blade used powerfully as a vectis accom- 
plished nothing. It was evident that neither Dr. B. nor 
I could succeed in this way. Proceeding to turn, I then 
found exactly what Dr. B. had described, viz., that the arrest 
was due to a circular uterine band, tetanically contracted a 
little below the shoulders of the child. Thus the knees were 
above this circular constriction on the right side of the ute- 
rus, and I toiled vainly without being able either to bring one 
down, or to push a leg by pressure from above through the 
right side of the uterine wall. All efforts at version by ex- 
ternal manipulation alone, or conjoined with the hand in the 
vagina, failed also, when I recommended craniotomy. Be- 
fore doing so, however. Dr. Bishop again renewed his efforts, 
and succeeded in bringing the left foot to the brim of the 
pelvis, from which place we could advance it no farther nor 
push up the head. 

It is important to mention that during the operations of 
Dr. .Bishop before my arrival, chloroform had been given, 
and that during all these efforts Dr. Case kept the patient as 
profoundly under its influence as possible, without in any 
way relaxing the tonic spasm of the fibres referred to. 

Careful exploration now enabled us to reach a loop of 
pulseless fanis, and thus all .objections to craniotomy being 
removed, I opened the head, and broke up the brain. Both 
the crotchet and the craniotomy forceps broke away piece 
after piece of the well-ossified head without advance. Under 
these circumstances, with the full approbation of the gentle- 
men present, I took the cephalotribe (Scanzoni's) and with- 
out any difficulty locked it, and crushed through one diame- 



200 OBSTETEIC CLIXIC. 

ter. Still my tractions did not avail, and it was thought bet- 
ter that it should be reapplied in an oj^posite diameter, which 
was again readily effected. Having again crushed through 
the foetal skull, by the unyielding grasp of this powerful 
tractor, I withdrew the head and overcame the obstacle. 
The child was a male, and of large size. Leaving the placen- 
ta to the management of Dr. Bishop, I was sm*prised to be 
called again to the bedside, to notice the curious way in 
which the constriction described had reproduced itself, or 
rather, perhaps, had steadily advanced with the altered ute- 
rine bulk, and now retained the placenta in an imperfect hour- 
glass contraction. This, however, did not make the removal 
of the after-birth (which was not adherent) an operation of 
difficulty, though it necessitated the introduction of the 
whole hand. In so doing the brim of the pelvis and lumbar 
vertebrae were carefully explored. 

Without the aid afforded by this powerful yet thoroughly 
manageable cephalotribe, I do not know how long it would 
have taken to overcome the singularly strong and tenacious 
grasp of this tonic uterine spasm. 

Mrs. recovered perfectly. 

Case SO. — Brov:^ and face ])re8entation ; povjerless labor 
vnth hand of circidar contracUd uUrine fibres j lever ; for- 
ceps ; partial version ; perforator. — Lying-in Asylum. — Dr. 
Sterling., Resident Physician. 

Mary Mack ; second pregnancy ; twenty-seven years old ; 
fell in labor on Friday night, December 5, 1S62. There had 
been some difficulty in her first labor. The doctor recog- 
nized a vertex presentation. Pains feeble and unsatisfactory, 
and her condition so feeble as to require stimulants. I was 
called to her on the Tth at noon. At that time she was weak, 
listless, and much fatigued, with no labor-pains of value. 
Foetal heart feeble, and heard with some difficulty on the left 
side. Yaoinal examination showed that the membranes were 



TOXIC CmCULAR CONTEACTION OF UTEEmE FEBKES. 201 

ruptured, and that there was miicli admixture of meconium 
with the liquor amnii, which latter seemed to have nearly all 
escaped. The anterior fontanelle could be reached high up 
on the left side near the acetabulum. The brow was the 
most depending part, but the nose, mouth and chin could be 
felt, the latter being du*ected toward the right sacro-iliac syn- 
chondrosis. The presenting parts were just within the brim, 
and readily movable ; I therefore determined to endeavor to 
bring down the posterior fontanelle. This was effected by 
the aid of one blade of the forceps, used as a lever, but when 
the instrument was removed the brow and face tended to re- 
sume their • original position. This led to an exploration 
with the object of determining whether an arm or other pre- 
senting part prevented the chin from remaining flexed. 'No 
such obstacles existed. The funis, however, was then dis- 
tinctly reached within the cervix uteri, not prolapsed, not rec- 
ognizably pressed u^Don, .but the pulsations were feeble, and 
by the watch amomited to 62 in the minute. It becoming 
therefore imperative that the labor should be promptly ter- 
minated, I explored still further, and recognized that the prom- 
ontory was unduly sharp, and more projecting than normal, 
though no diameter in the brim or elsewhere offered any im- 
pediment to the labor. ISTor, indeed, could the head be said 
to have yet engaged in the brim. Further up there existed 
a band of circular uterine fibres, unduly and tonically con- 
tracted, the contraction not bearing any relation to the de- 
gree of contraction in the other uterine fibres. Here seems 
to me to have been the key to the position ; for, as I have 
seen in similar cases, the circular constriction prevents alike 
the weight of the child from aiding its descent after the wa- 
ters are evacuated, and prevents the uterine contractions from 
being regularly transmitted through the spinal column to the 
foetal head ; thus such result being prevented, the long arm 
of the lever, or that passing from the plane of the spine to 
the frontal bone, is no longer pressed upward, flexion of the 
chin on the breast no longer follows, and the head, swinging 



I 



202 OBSTETEIC CLINIC. 

at the brim of the pelvis, is left free to the other influences 
which, in such a state of things, would invite descent of the 
forehead, just as would happen if a still-born child were held 
up by its heels after birth. 

This state of things — the peculiar character of the labor, 
and the feeble funis-beats — called for prompt relief. Having 
then reapplied one blade of the forceps, and again brought 
about and maintained flexion of the chin on the breast, I ap- 
plied both blades and locked them. The instrument was thus 
readily applied above the brim, in the oblique diameter, run- 
ning from the left sac.-il. sjn. to the right acetabulum. When 
tractions were forcibly made, however, the head pivoted again, 
so as to resume its original position. For this I was quite 
prepared, as I had met the same difficulty before in just such 
a case, and making no further infructuous efi'orts I withdrew 
the instrument, and attempted version. 'No great difficulty 
was experienced in bringing down both feet, one to the vulva, 
and one just within. But the difficulty was, of course, to 
come, viz., to push up the head through the circular constric- 
tion. Before proceeding to that manoeuvre I felt again for 
the funis, which had not prolapsed, and found it pulseless. 
This fact being also recognized by Dr. Sterling, obviated the 
necessity for continuing an operation which could not benefit 
the child, and so, having pushed up the feet, and requested 
Dr. S. to maintain the head fixed at the pelvic brim by pres- 
sure through the abdominal wall, I perforated the foetal 
skull with Blot's instrument, and with strong and somewhat 
continued efforts withdrew the child by the aid of Church- 
ill's crotchet. After the head was withdrawn, time was 
allowed for the uterus to contract and aid in expelling the 
body; but it remained sluggish, and after some time the 
placenta was withdrawn fi-om its usual site — ^hanging over 
the anterior cervical lip. Contraction was maintained for 
some time by the hand before the binder was a^^plied, and 
by the aid of ergot and brandy there was no hemorrhage, 
and the patient did well. Chloroform. 



TOXIC CIKCULAK CONTEACTION OF UTEEINE FIBEES. 203 

Case 81. — Contracted conjugate diameter ^ tonic contrac- 
tion of uterine fibres circularly above the cervix / exhaustion 
of mother ; failure of forceps, twice apjolied, after an interval 
of three hours j imjpossibility of version j craniotomy; re- 
covei'y of mother. — Bellevue Hosjpital. — Dr. Baphael, House 
Surgeon. 

Mary Eeynolds ; single ; aged 28 ; Irish. Menstruated 
last in September, 1862. Taken with, labor-pains at 9 p. m., 
June 28, 1863, which scarcely allowed her to sleep during 
the night ; and by 11 a. m., June 29th, the os was fully di- 
lated, and the presentation easily ascertained to be L. O. A. 
The membranes ruptured at about this time, and the pains 
increased in severity and duration through the day, without, 
however, influencing the progress of the child. 3 p. m. — 
Foetal heart beating distinctly. 5 p. m. — Patient shows evi- 
dent signs of exhaustion from the severity of the pains, 
which have continued all day, with scarcely an intermission ; 
and as she had not slept any during the day, and scarcely 
any dmung the previous night, she was kept under the influ- 
ence of chloroform for two hours, when she awoke and ex- 
pressed herself as much refreshed. At 8 p. m. the pains set in 
again with full force, the woman at the same time bearing 
down with all her power, without, however, doing more than 
wedging the head into the brim of the pelvis. At 9 p. m. 
Dr. Elliot examined the patient again, and found that the 
head had escaped pretty well through the cervix uteri, but 
that above the head a band of tonically contracted circular 
fibres prevented the advance of the child. In addition to 
this he diagnosticated that the antero-posterior diameter of 
brim was contracted to 3f inches. Members of the house- 
staff were invited to feel the circular contraction of the uterus, 
and distinctly recognized it. Dr. E. then applied his forceps, 
the application of which was difiicult, but thorough tractive 
efforts failed to advance the head. Yesion was rendered 
impossible by the condition of the uterus. As the general 



204: OBSTETEIC CLrNIC. 

condition of tlie patient was still good, Dr. E. decided to 
wait three lionrs longer. Pulse 85. Parts still moist and of 
good temperature. Foetal heart beating. June SOth, 1 a. m. 
— Condition of the patient has materially changed. She 
appears to be much exhausted ; is restless and irritable. Parts 
are now hot and dry. Pulse 100. Foetal heart scarcely au- 
dible. Xot the slightest advance of the head. Dr. Elliot 
again applied forceps, and made a thorough but unsuccessful 
effort to advance the head. He then performed craniotomy 
and delivered the head with some difficulty. The passage of 
the child's body was comparatively easy. Child estimated to 
have weighed (with the brain) about 9 pounds. Forty min- 
ntes afterward the placenta came away with but slight hem- 
orrhage. July 1st, 8 A. M. — Patient slept some five hours, 
and feels comfortable. Looks very much debilitated, and 
pale. With stimulants and nom-ishing diet, she made a slow 
but good recovery, and left the hospital on the 18th of July. 
jRemarJcs. — In this case I was obliged to perform crani- 
otomy while yet the foetal heart was beating — the saddest 
and the most melancholy duty that can fall to the lot of an 
obstetrician ; very rarely, indeed, if ever necessary, but as I 
believe unqualifiedly justified in this case by the record, and 
heartily approved by all present. To have waited longer 
would have perilled the mother's life too greatly, not only on 
account of the condition to which she had been reduced, but 
on account of the tendencies to fever existing in the hospital. 
Still, notwithstanding that it was done for the best after care- 
ful consultation, and notwithstanding that I have been per- 
sonally responsible for cases in which a similar treatment 
might have been as beneficial to the mother, I do not think 
I can ever bring myself again to the performance of so horri- 
ble a task. 

Case 82. — Forcejps / jperitonitis / tendinous tand in vagina. 

Dr. W. W. Jones sent for me to see this patient, and has 
kindly written the following history of the case : 



FOECEPS FOE TENDINOrS BAND m THE VAGINA. 205 

" Mrs. E. C ; 23 years of age ; primipara ; was taken 

in labor on the morning of ^N'ovember 30, 1859. During tlie 
day tlie pains were sliglit, bnt in the evening they became 
strong and regular. The head presented in the left occipito- 
anterior position. At 12 p. m. the os uteri was fully dilated, 
the membranes ruptured, and the head had descended nearly 
to the perineum. After this, though the pains were vigorous, 
there was no further advance. On searching for the cause of 
the delay, a firm, tendinous band was found, stretching across 
the upper part of the vagina, on the right side, which resisted 
any frnther advance, though the head was forced strongly 
against it with each pain. After some homes' delay, a vein 
was opened and a moderate amount of blood taken. Decem- 
her 1st, 10 a. m. — The head remaining in the same position. 
Dr. Elliot saw the patient. Chloroform was given at once, 
and Dr. E. proceeded to dehver by the forceps. The blades 
were applied with great facility, but, though powerful trac- 
tion was made, the head could not be moved. Dr. E. then 
withdrew the instrument, and reapplying it in a different 
position, rotated the head, and effected the delivery. The 
child was born asphyxiated, but by plunging it alternately 
into warm and cold water, and by artificial respiration, it 
was perfectly restored. E'otwithstanding the force required 
in effecting the delivery, there was no abrasion, and hardly 
the slightest mark on the child's head or face. Immediately 
after the delivery a full dose of ergot was given, and the 
uterus contracted firmly. December 3<^.— To-day was taken 
with symptoms of peritonitis. Ten grains of the mild chloride 
with one-eighth of a grain of the sulphate of morphia were 
given, followed by castor-oil, hot fomentations applied to 
abdomen, and, as soon as the bowels were moved, she was 
put on ten drops of Magendie's sol. sulph. morph. every two 
hours, so as to produce narcotism — ^beef-tea given freely. 

" This was continued until December 5th, 10 a. m., when 
it was found that though the pain was relieved, and the res- 
piration very much reduced below the natural frequency, the 



206 OBSTETEIC CLINIC. 

pulse had risen to 160 beats per minute. She was then put 
on tinct. verat. vir. three drops, gradually increased to nine 
drops every three hours. This rapidly reduced the pulse, 
bringing it down in twelve houi's below 100, and in twenty- 
four hours below 60. As the effect of the morphine subsided, 
the pain returned, and it was found necessary to alternate 
the remedies. She was also early in the disease put on the 
use of stimulants. December Sth. — ^Patient materially im- 
proved, and on the 12th convalescent." 

Remarks on Brow and Face Presentations. — Cases 79 
and 80 offer examples of a comparatively rare cause of 
brow presentation, while they illustrate both the facility 
with which the head can be flexed by the hand under 
these circumstances, and of the futility of the effort to secure 
a permanent result, as the long arm of the lever falls so soon 
as the hand is withdrawn. In cases, however, in which brow 
or face presentations occm- from other causes, such manipu- 
lations may often result in a successful and permanent con- 
version of the presentation. 

Case 83. — Forehead ^presentation converted hy conjoined 
manipidation into that of the vertex. — Dr. Francis Delafield^ 
House PhysicioM. 

Mary Madden, aged 28, married, primipara. Labor com- 
menced in the lying-in wards of Bellevue, October 23, 1863, 
9 p. M. Membranes ruptured 1 p. m. October 24th, at 3 p. m., 
Dr. Elliot saw the case and recognized a forehead presenta- 
tion, the chin pointing toward the left sacro-iliac synchon- 
drosis. The OS uteri was soft and well dilated ; the child's 
head had just engaged in the superior strait. The uterine 
contractions were feeble, and the foetal heart distinctly audi- 
ble. The patient was placed under the influence of chloro- 
form. Dr. Elliot, then introducing his right hand into the 
vagina and with his left pushing down the occiput through 
the abdominal wall, succeeded in flexing the head and con- 



MANUAL CONVEESION OF FOREHEAD PRESENTATION. 207 

verting the presentation into a right occipito-transverse posi- 
tion. After the operation the foetal heart conld be distinctly 
heard in the right iliac region. At 5.15 p. m. the head was 
in' the same position, partially engaged in the snperior strait, 
and a little more flexed. At 7.20 p. m. the head was fairly 
engaged in the superior strait, strongly flexed, and the occi- 
put had commenced to rotate toward the symphysis pubis. 
The uterine contractions were now of considerable force, and 
at 9 p. M. the occiput had completely rotated under the sym- 
physis, and the child was born. There was a slight delay 
between the birth of the head and that of the shoulders. 
The child respired a few times, and the heart continued to 
beat for three-quarters of an hour, at the end of which time 
the child was dead. All the usual methods for restoring 
animation, hot and cold water, artificial respiration, etc., 
were continued until death, without effect. The placenta 
came away at 10 p. m. Child female, weight seven pounds 
eleven ounces. Mother did well. 

Autojpsy of Child seventeen Hours after Death. — 
Weather cold. Cause of death not evident, though every 
organ of the body was examined with care. There was some 
congestion of the brain and liver, but not such as could be 
pronounced a cause of death. No extravasation. Lungs par- 
tially inflated, and presenting neither ecchymoses nor liquor 
amnii, nor evidences of ante-partum respiration. Heart and 
vessels normal. Peritoneum healthy. It was interesting to 
observe on the posterior wall of the uterus the evidence of 
congestion of vessels parallel to each other, and running down- 
ward obliquely on either side from a line drawn longitudi- 
nally, as it were, along the raphe of the uterus. The broad 
ligaments were also markedly congested, and the fundus of 
the uterus, instead of being flat, was markedly convex. 

Doubtless the death of the child may have been occa- 
sioned by pressure on the cord during the interval of the 
time between the birth of the head and the shoulders, men- 
tioned by Br. Delafield. Still there were no satisfactory 



208 OBSTETRIC CLINIC. 

patliological evidences of such, a mode of death. I confess to 
an inability to distinguish in these neonati sucli congestion 
of the brain as may be recognized as a cause of death, un- 
less some extravasation can also be found. I did anticipate 
that the manipulation described might have induced such, 
premature respiratory efforts as are now well knovm to be a 
cause of fcBtal death, but a careful examination proved the 
contrary. "Whether this case had passed on with the fore- 
head as the presenting part, or had been converted into that 
of a face ; in either event, with the chin to the left sacro-iliac 
synchondrosis in a primipara of twenty-eight, the prospects 
were far from satisfactory. 

In my experience brow presentations have proved very 
dangerous to foetal life, unless the child, or the child's head, 
were small in comparison with the mother's pelvis. 

Dr. Geo. A. Peters saw an interesting case in my prac- 
tice where the brow came down more than once after it had 
been returned by the hand, when after again producing 
flexion I delivered an occipito-posterior presentation with 
forceps, and mother and child did well. In a previous labor 
of this patient I had turned a second twin vdth great facility 
by external manipulation alone. 

In two cases of ruptured uterus under my observation, 
the brow presented, though I do not attribute the result to 
this fact alone, as in one there was marked anterior uterine 
obliquity, and in the other the tips of the fingers of the hand 
had been felt by the head, while there was no microscopic 
examination made of the uterine fibres themselves. One 
of these was rendered remarkable by the recovery of the 
mother. 

Case 84. — Bupture of uterus i presentation of l)row, 
hand^ and funis / delivery ly version and the crotchet / 
EECO YER Y of mother. 

On Thursday, K'ovember 25, 1860, I was called by Dr. 
Slevin to see Mrs. McDonald, in labor with her second child. 



EUPTUEE OF TITEEIJS. 209 

The first labor had been severe, but had terminated naturally, 
and the child was living. The present one had continued 
for eighteen houi's, when the patient complained of a sharp, 
agonizing pain in the left iliac region, and no more uterine 
contractions took place. Before this event Dr. Slevin had 
recognized the presentation of the brow, and the tips of the 
fingers of one hand, but no effort had been made at any 
obstetric operation, nor had any oxytocic preparation been 
given. Subsequently to the occurrence of the sharp pain 
referred to, the presenting parts had receded, and Dr. Slevin 
had diagnosticated rupture of the uterus. "When I saw her 
she was very weak, unwilling to stir, or permit pressure over 
the seat of pain, and vomiting a clear green fluid. Pulse 130 
and feeble. On vao-inal examination I recognized the brow 
above the plane of the superior strait, the fingers of the left 
hand by the side of the head, and a loop of pulseless funis. 
Within the cervix, to the left, was a longitudinal fissure 
which did not involve the entire thickness of the cervix. 
We decided on version, and after giving the woman some 
stimulus, and getting her in position, with the hips over the 
edge of the bed, I proceeded to perform that operation — no 
ansesthetic being given on account of the collapsed condition 
of the patient. The dorsum of the child being next the ab- 
domen of the mother, I passed my right hand gently along 
the posterior uterine wall, and disregarding the right hand, 
which was on a level with the foetal face, the right foot was 
soon reached, and after drawing that without the vulva, the 
other was readily disengaged, and the arms gave no trouble. 
]^ot withstanding all my care, however, extension of the head 
took place, and the chin became firmly lodged against the 
left ilium, nearly on a line with the linea ileo-pectinea. 
Manual efforts having failed to complete the delivery, and 
the child being dead, I passed the blunt hook within the 
mouth, and pressing the perforator strongly against the 
occipital bone, fractured the jaw-bone without dislodging 
the head, and then having perforated the occipital bone, and 
14 



210 OBSTETRIC CLIXIC. 

evacuated the brain, the delivery was terminated witli tlie 
crotcliet. Mj hand being now introduced within the vagina, 
enabled me distinctly to recognize that the longitudinal fis- 
sure referred to (as recognized in the cervix before delivery) 
extended through the left side of" the uterus, and on passing 
two fiiigers through the rupture into the abdominal cavity, I 
touched a loop of intestine, and the peritoneal coat of the 
abdominal wall. The other hand placed over the left iliac 
region enabled me distinctly to appreciate that nothing but 
the abdominal wall was interposed between them. 

On removing my hand I withdrew the placenta without 
difficulty, nor did any hemorrhage of moment take place. 
Contraction of the uterus followed, and was aided by |ij. 
of the satm^ated tincture of ergot and by ice in the vagina. 
Most of the ergot was vomited, however, though the color of 
the fluid rejected by the stomach had become so dark before 
its exhibition as to be scarcely affected thereby. 

The patient being replaced in bed, and the best measures 
taken to promote reaction, we felt obliged to give the most 
unfavorable prognosis possible, and separated without making 
any appointment for further consultation. The child was a 
male, and of large size. 

On the 26tli [N'ovember, being in that vicinity, I called 
to learn her fate, and found her doing moderately well — the 
vomiting still persistent — ^pulse 100. 

December 4th, I again saw her — the abdomen swelled and 
tender — some milk — no lochia. 

In the latter part of the month I again called, and found 
that she was out walking, and had quite recovered. 

Dr. Slevin informs me that he treated her with a mod- 
erate use of sedatives and stimulants. 

Case 85. — Rujptured uterus '^ version; anterior uterine 
obliquity ; trow presentation. 

JSTovember 24, 1860, I was called in consultation, by Dr. 
Owen Sweeney, to Mi's. , and found Dr. Bishop and Dr. 



KUPTUEE OF UTEEUS. 211 

James Sweeney present. The patient was a multipara, who 
had been apprehensive of the result of this confinement from 
the great anterior obliquity of the uterus. The mem- 
branes had ruptured at the commencement of labor, and Dr. 
Sweeney had recognized the forehead as the presenting part. 
The labor was tedious, and the pains not remarkably severe, 
but referred, for the most part, to the right iliac region. 
TVith the aid of a sheet. Dr. S. gently and carefully strove to 
remedy the great uterine displacement, the patient resting 
on her back. No oxytocic preparation was used, nor was 
any thing done to advance the labor beyond the means re- 
ferred to. After some twenty-four homes' the patient com- 
plained that the pains were very severe, and different from 
labor-pains, referring her chief sufferings still to the right 
iliac region. Collapse soon followed, with total cessation of 
uterine contractions, and much vomiting of a dark fluid. Six 
hours subsequently I saw her, and found her collapsed, cold, 
pale, and with a feeble pulse. The marked anterior obliquity 
was very striking, though not so much as Dr. S. had pre- 
viously observed. Pain was complained of on pressure over 
the right iliac region. Yaginal examination disclosed an ex- 
tensive laceration of the posterior lip and vaginal cul-de-sac, 
through which the whole hand readily passed into the peri- 
toneal cavity, where the head of the child could be distinctly 
felt to the right of the lumbar vertebrae. So near death did 
she seem — the child being so already — that I felt loath to em- 
bitter her last moments by an operation; to which conclusion 
the gentlemen present had already arrived. We separated, 
with the understanding that if she could be rallied we would 
meet again. Dr. Sweeney succeeded in doing so, and in 
about ten hours we met again. Dr. Bishop having distinctly 
appreciated the condition of things, I turned with facility, 
and delivered by the feet a well-grown dead child. 'No chlo- 
roform. The uterus contracted well, but she died in about 
fourteen hours. No post-mortem. 

RemarTts. — Although I cannot imagine that the &te of tliis 



212 OBSTETEIC CLmiC. 

poor woman would liave been changed if version had been 
performed at an earlier period of labor, I am still sure that 
it was very wi'ong to yield to the extreme reluctance which 
one so naturally felt to subject the poor creature to the oper- 
ation of version while so near death. 

In addition, however, to the effect produced on all the 
consultation by the piteous condition of our patient, we re- 
called the fact of our having all met together but a few 
months before by the bedside of a woman believed to be the 
subject of the same accident, although the precise site of the 
laceration was not determined. In that case the patient was 
collapsed when I saw her ; still I delivered by version, but 
she only survived three hours. 'No chloroform. 

While it would be my endeavor to convert a brow pre- 
sentation either into that of the posterior fontaneUe, or into 
that of a frank face presentation, my experience has taught 
me both that the manipulation is not always successful, even 
when aided by the vectis; and also that occasionally the 
brow will slip down again after the hand or instrument is 
withdrawn, even when no cause exists, such as obtained in 
cases Y9 and 80, and when nothing prevents perfect flexion 
of the head — such an obstacle, for instance, as the hand or 
arm of the child in front of the neck. 

I am well aware that the contingency of a brow or chin 
presentation (or rather the fact that one of these points should 
be lower than the rest of the face) is considered as an acci- 
dent not materially influencing the progress of the labor, and 
capable of restitution in the movement of descent. And I am 
very sure that one has a perfect right to anticipate, or at least 
hope for, such a termination. Still it has so far happened 
in my experience that these cases of brow presentation have 
been apt to exhibit untoward results, and to demand inter- 
ference. Such facts may have been exceptional, but still, in 
the practice of my friends, two such cases have been men- 
tioned to me at their commencement ; and while in both I 



EUPTUEE OF UTEEIJS. 213 

-fished tlie plijsicians better luck than I liad sometimes met 
mtb, in both, as I was subsequently informed, the delivery 
was finally accomplished after perforation. 

Case '$>^.^B,ujpture of lUeriis j jpatient died undelivered, 
— Dr. Hawthorn^ House Physician, 

This patient, named Canet, in the eighth month of her 
ninth pregnancy, was admitted into Bellevue under the fol- 
lowing circumstances. She had been under the care of 
three physicians — names unknown — for uterine hemorrhage, 
supervening on violent exertion. Subsequently, Drs. Gris- 
com and Connery were called, as her former physicians had 
left and did not propose to return. She was then flowing, 
nearly pulseless, complaining of burning pain in the epigas- 
trium, and vomiting incessantly. The hemorrhage was 
checked by acetate of lead and opium, the pain somewhat 
soothed by a hop-poultice. Suspecting placenta prsevia. Dr. 
C. introduced an alum-plug and sent her to the hospital. She 
entered September 23d, 1859, moribund, and unable to re- 
tain any thing on the stomach or in the rectum. ITo hemor- 
rhage. A tampon was introduced by Dr. Hawthorn as a 
precautionary measure, and Dr. Elliot sent for. On his 
arrival he removed the tampon and found the os dilated 
to the extent of one and a half inches, and not further 
dilatable. Patient evidently not at full term. The cervix 
contained offensive clots and shreddy material, but the pla- 
centa could not be reached. The abdomen was much swol- 
len, excessively tender, and very emphysematous below the 
umbilicus, especially in the right iliac region. The outlines 
of the uterus could not be mapped out, nor could an extra- 
uterine foetus be detected through the abdominal walls. 
Neither foetal heart nor uterine souffle audible. The flow 
had completely ceased. Under these circumstances delivery 
being impossible 'jper vias naturcdes^ Dr. Elliot requested that 
compressed sponge should be introduced within the cervix, 
and the tampon be applied in the event of the return of hem- 



214 OBSTETRIC CLINIC. 

orrhage, and that the patient should be stimulated by ene- 
mata and the hot-air bath. 

Dr. Hawthorn had already bandaged the legs. Br. Elliot 
requested that a consultation should be called for four 
o'clock (one and a half hoiu-s later), but the patient died 
half an hour afterward, after an access of Yomiting. The 
uterine hemorrhage had not returned. The hot-air bath 
produced perspiration almost immediately, and was, there- 
fore, stopped. 

Autopsy, eighteen Tioiirs after death. — Weather murky 
and warm ; cranial and thoracic cavities not opened. Much 
frothing at the mouth. Abdomen stained green around the 
umbilicus and at the sides. Tympanitic. Emphysema 
within abdominal cavity quite appreciable. Abdomen 
opened by crucial incision, and was followed by a great es- 
cape of gas. ^o emphysema of abdominal walls. Perito- 
neum intensely injected. Clotted blood removed to the ex- 
tent of twenty-four ounces avoirdupois, and a large quantity 
of fluid blood escaped without its amount being appreciated. 
The foetus in its amnion, and with a greater part of the de- 
composed placenta attached, was found in the cavity of the 
abdomen. The foetus crepitated on pressure, and the bones 
of the head moved on each other. The well-known attitude 
of the foetus in utero was preserved. The intestines were 
removed, and the blood sponged out, when the rent in the 
uterus was distinctly seen to extend from the centre of the 
fundus along the mesian line downward, and laterally for 
^\Qi inches and a half, '^o laceration of the vagina — vaginal 
walls crepitated on pressure. Eingers introduced within the 
vagina visible through the uterine rent. Pelvis normal, with 
the exception of the spine of the right ischium, which was 
somewhat elongated and turned up. No bony projection, 
sharpness, or spicula to be found, which could have influ- 
enced the case. The uterus was put in alcohol, and micro- 
scopic examination omitted. The specimens were all shown 
at Dr. Elliot's clinic in the College of Physicians and Sur- 
geons, September 30, 1859. 



FACE PKESEXTATION. 215 

Case ST. — Bight mento-iliac presentation j death of child; 
ergot; craniotomy. — Bellemie — Dr. Wm. T. J^ealis^ House 
Physician. 

Hosanna Sexton; Irisli ; aged 25 ; primipara ; admitted 
to Ijing-in ward October 21, 1862. Has been suffering from 
pains in the back since the 19th instant. As the labor-pains 
were ineffectnal, a comfortable night's sleep was produced by 
McMnnn's elixh\ During the 22d the pains were at long 
intervals, and of no great force, the os uteri being only 
slightly dilated. At 9 p. m. five drops of Magendie's solu- 
tion of morphia were given, which produced a comfortable 
sleep. During the 23d the pains came on at shorter inter- 
vals, and with greater force. The membranes ruptured at 
noon. At half-past 1 p. m. Dr. Elliot saw the patient, and 
recognized a right mento-iliac position of the face, and 
thought the child dead, as there was no foetal heart audible, 
and no motion 'svhen the finger was introduced into the 
child's mouth. He ordered a drachm of the tincture of ergot, 
which acted very speedily, and produced powerful pains; 
but there was no advance of the head, the chin remaining in 
the same position when Dr. Elliot saw the patient again, 
seven hours after. Dr. I. E. Taylor and he then decided on 
perforation, which was done by Dr. E., after Dr. Mola had 
given chloroform. Dr. Thomas's perforator was introduced 
into the right temple, close to the orbit, and the child deliv- 
ered. A half-ounce more of ergot was given, but as no pains 
followed, the placenta was removed by the hand two hours 
afterward. Uterus contracted well. JSTo hemorrhage. On 
the niaeteenth day the patient left the hospital in perfect 
health. 

Case 8.8. — Shoulder and arm presentation ; cephalic vei"- 
sion hy external rnanijoulation^ aided ly "oectis and forcejps.^ 
ineffectual to flex the head ; jpodalic version and perforator. 
— Bellevue — Br. Charles B. White, House Physician. 

Ann Power ; single ; aged 30 ; second pregnancy. Labor 



216 OBSTETEIC CLINIC. 

commenced April 10, 1867, at 11 p. m., and terminated on 
the llth, at 6.30 p.m. First stage, twelve lionrs ; second, 
seven and a half. Female child, still-born. Weight, six 
pounds six ounces, without the brain. 

The waters broke at the commencement of the labor, but 
the OS was so high up and undilatable that Dr. White did 
not distinguish the presentation until about 8 a. m. on the 
11th, when he recognized the left shoulder, shortly before the 
arm came down in the vagina. I was sent for about noon, 
and went immediately, and by external palpation recognized 
the head above the pubis in front, and determined to convert 
the presentation into a cranial one. Having carried the arm 
within the uterus above the chin of the child, I succeeded 
by external manipulation in bringing down the head to the 
brim in a transverse position, nor did the arm again prolapse. 
All my efforts, however, even though aided by one blade of 
the forceps, used as a vectis, failed to flex the head, the fon- 
tanelles remaining obstinately in nearly the same place. 
Still hoping that time and the advance of the labor might 
bring this about, I requested the house physician to maintain 
pressure against the brow (per vaginam) during the uterine 
contractions, which continued strong and frequent. At 5 
p. M. I returned, with Dr. Taylor, and found that nothing 
had been gained ; on the contrary, the anterior fontanelle 
had descended somewhat. With his approval I now applied 
a vectis to the occiput, and made powerful but ineffectual 
efforts to flex the head. Pulse good. Condition of vagina 
good. Patient somewhat weak. Gave some wine, and hav- 
ing ansesthetized with chloroform, I apphed the forceps and 
endeavored, unsuccessfully, to bring about some advance. 
As the foetal heart was beating, there remained the necessity 
for podalic version, which I had desired to avoid. Having 
delivered the body and the arms, the chin was found extended 
and so fixed that I could not move it, and I requested Dr. 
Taylor to try. He made every effort to do so, but did not 
succeed ; so I pressed the perforator into the back part of the 



FACE PEESElsTTATION. 217 

neck, and sheathing it in these tissnes, penetrated the occipi- 
tal bone, and delivered with a crotchet. For some days after 
the mother had a qnick pnlse, with tympanites, pain, fever, 
and slight dehrinm, bnt entirely recovered, by the aid of 
morphia, turpentine stnpes to the abdomen, and warm 
fomentations to the vulva. 

Management of frank face presentations. — In frank 
face presentations, when the chin is directed in front, the 
head well proportioned, and the parts well relaxed, it is 
probably better not to interfere at all. The risks of failure 
and of inducing premature respiration may be set against 
the slight risks from difficulty associated with the presen- 
tation itself. Every now and then men come forward 
with claims for manual interference in all of these cases, 
as if the proposition were a new one, and as if by general 
consent the profession had not settled down to the conviction 
that interference was to be reserved for those positions with 
which additional danger is associated. As a rule, under the 
circumstances we are now considering, the labor passes on 
quietly and natm-ally ; and if unnecessary manipulation be 
withheld, the face at last peers out from the vulva as from a 
frame, recedes in the intervals of the pains, and finally passes 
naturally into the world with only the likelihood of a disa- 
greeable but temporary ecchymosis. 

The result may be very much modified by the continued, 
unnecessary, and awkward manipulation of an inexperienced 
physician, uncertain of his diagnosis. 

Case 89. — Locked face jpresentation / effects of manipula- 
tion / forceps ; perforator. 

Many years ago I was called in consultation to a case of 
face presentation with the head of the child wedged in the 
pelvis ; and by my invitation Dr. Metcalfe, and then Dr. Chas. 
D. Smith, also saw the patient, who was a primipara. The 



218 OBSTETEIC CLINIC. 

presentation had not been recognized, and the eje had been 
pushed out by repeated examinations, and hung from the 
denuded orbit. JSTo foetal heart. I applied two different pairs 
of forceps, and neither Dr. Metcalfe nor myself could move 
the head; when I perforated through the orbit, and the 
mother made an excellent recovery. 

If the young practitioner be led to believe that it is ne- 
cessary to interfere in every case of face presentation, he may 
be exposed to the annoyance experienced by a gentleman to 
whom I heard Prof. Simpson allude in his lectures. This 
young gentleman had recently settled in a small town in 
Scotland, and met with an ordinary face presentation in his 
first case of labor ; which, from the character and position of 
the patient, attracted great attention in the town. Consci- 
entiously believing that interference was necessary, he frankly 
stated the situation, and sent a messenger on horseback in 
hot haste for an experienced practitioner many miles away. 
This heartless man, hearing the full details of the case from 
the panting messenger, yawned and yawned in the cool night 
air, and asked how much time had been spent on the road ; 
when, yawning again, he advised the man to ride back qui- 
etly, as there was no necessity for any assistance, and the 
baby would surely be born before his return. Unluckily for 
the young doctor, this was the fact ; and the story was so cir- 
culated that he found it desirable to take a fresh start in 
another place. 

Chin posteriorly. — ^In cases, however, where the chin is 
directed posteriorly, the risks are greater, although it is my 
belief that it rotates anteriorly more generally than some 
eminent authorities are willing to admit. In two cases of 
this character which I have witnessed, where experienced 
men have performed version for the purpose of saving the 
child from the risks attending this position of the face, the 
children have been delivered still-boi^n. It is my impression 



f 



FACE PRESENTATION. 219 

that it is better, as a rule, to trust to nature than to perform 
version in these cases ; bnt that the endeavor to convert the pre- 
sentation into that of an occipital may be preeminently indi- 
cated. If, however, we cannot succeed in the manoeuvre, 
we may assist the rotation anteriorly by coaxing the chin 
around when opportunity serves us, or we may effect the ro- 
tation by the vectis or with the forceps. In these operations 
we can facilitate the rotation by external manipulation 
through the abdominal walls ; and we must not take all the 
credit in these, or occipito-posterior cases, for too prompt 
success, since our interference may have fortunately coincided 
with the spontaneous movement of the head. On the other 
hand, we must not be precipitate and harsh, for fear of twist- 
iug the child's neck too strongly, and thus interfering with 
the cerebral circulation. 

I have had no experience in converting cranial into face 
presentations for facilitating delivery through a contracted 
brim. 

ISTotwithstanding the ingenious arguments which have re- 
cently been presented in England, I cannot regard a natural 
delivery of a face presentation with the chin persistently di- 
rected posteriorly as other than an exceptional incident, and 
not safely to be anticipated in any given case. 

Case 90. — Face presentations ; rotation of chin to ^pubis 
with forceps. — Bellevue — Dr. C. Haasse, House Physician. 

Mary Jones, aged 19; first.. In labor from ITovember 
10, 1857, 11 p. M., to 12th, 6.40. Child, girl, weighing 8^ lbs. 
Both did well. First seen November 11th, at 2 a. m., by Dr. 
Haasse. Os just admitted the finger. Membranes broke at 
4 A. M. Os then dilated to the size of half a dollar. Pains 
good, but little progress till 9 A. m., when they ceased. Mor- 
phine then enabled her to sleep from 10 a.m. till 3 p.m. 
Dr. Haasse then made out face presentation. Caput succe- 
daneum on right frontal protuberance. Chin directed nearly 



fll 



220 OBSTETEIO CLINIC. 



back to right sacro-iliac syncliondrosis. 5|- p.m. — 'No per- 
ceptible progress. Dr. Elliot delivered a living cbild witb. 
Simpson's forceps, rotating &st the chin to the pubis. 

Further illust/rations of the use of the hand in facilitating 
lahorT" — ^Yiardel was right in claiming advantages from a 
more extended use of the hand in obstetric operations, al- 
though his devotion to a single idea induced him to overstate 
its advantages. We may occasionally ward off serious risks 
by timely use of conjoined or bi-manual manipulation, as 
in the following case. 

Case 91. — Case of twins in ajpelvis with conjugate diam- 
eter of three inches and a half ; rish of locJcing of the heads 
prevented hy manipulation. — Dr, Francis Delafield., House 
Physician^ Reporter. 

Mary Hoey, aged 24, unmarried, primipara, fell in labor 
in the lying-in wards of Belle vue, October 14, 1863, 6 a. m. 
Patient first seen October 14:th, 7 p. m. At that time the os 
uteri was soft and dilated; membranes not ruptured; no 
presenting part within reach. Uterine tumor large and pro- 
jecting forward. Contractions feeble. 9.15 p. m. — Dr. ElHot 
saw the case. Membranes not yet ruptured, but very tense, 
thin, and protruding through the os. E"o presenting part to 
be reached (tension of membranes preventing). The sacral 
promontory is felt projecting, leaving an antero-posterior 
diameter of about three and a half inches. The abdomen 
presents a large projecting tumor, with a sulcus apparent to 
the right of the median line. One foetal heart can be heard 
about four inches below the umbilicus and a little to the left 
of the median line. Dr. Elliot stated his belief that the case 
was one of twins superimposed. The membranes then rup- 
tured spontaneously, when two heads could be felt present- 
ing. One to the left and superiorly, with its membranes 

* Yide New YorJc Ifedical Journal for June, 1866, for an "Historical and 
Bibliographical Xotice of Cosmo Yiardel," by the Author. 



USES OF THE HAOT). 221 

still nm-nptiired ; the otker (of which the membranes had 
ruptm-ed) to the right and beneath. The lower seemed like- 
ly to advance first and catch beneath the upper. Dr. Elliot 
feared the risk of locking, and rnpturing the membranes of 
the upper child, he placed his hand on the abdominal wall 
over that head, which was superior and to the left, and 
forced it into the pelvis in advance of the other. The con- 
tractions now became more powerful, and continued until 
2 A. M., when the head which had been pressed down was 
first delivered, with the occiput under the pubes. In fifteen 
minutes the second child was born, full rotation not having 
taken place. At 2.30 A. m. the placentae were born within a 
few minutes of each other. They were entirely distinct, and 
each complete in itself. 1st child, female, 4 lbs. 4 oz. ; 2d, 
male, 4 lbs. 8 oz. Both living. Measurement of conjugate 
confii-med with the finger after delivery. 

Remarks. — ^ow, had I seen this patient before labor set 
in, and recognized the deformity, I might have been greatly 
embarrassed by the difficulties in the way of reaching the 
presenting part of the child. It is probable that, as I diag- 
nosticated twins before the waters broke, I might have made 
that diagnosis before labor set in. In these and similar con- 
tingencies, the pelvis being deformed, and the woman en- 
ceinte autant qy)on pent Vetre^ I consider that premature 
labor would have been indicated ; nor am I sure that when 
the small size of the children is noted, and the liability to 
prematiu-e labor in twin eases remembered, the case may not, 
after all, have been one of spontaneous premature labor. It 
has occurred to me that there might be some embarrassment 
in such a procedure as was practised here, in countries where 
the rights of primogeniture might have thus been summarily 
decided by the accoucheur in favor of a particular twin, had 
both been boys. Still, in this procedure, the twin excluded 
from the birthright could not even claim, on such evidence 
as that of the scarlet thread in the case of Tamar, the 
daughter-in-law of Judah. 



222 OBSTETEIC CLINIC. 

Benjamin Piigh. — Tlie practical recommendations of 
this excellent accouclienr suggest a practice which has 
attracted httle attention in the books, ahhough his plan of 
giving air to the child has been revived in our times. 

Speaking of cases of pelvic presentations, original or con- 
verted, in which delivery of the head is so difficult that the 
alternative of perforation must be considered, he says ; 

" "When you find this to be the Case, keep your Left hand 
still in its Place ; never let that go ; desire the l^urse or one 
of the most handy Women about you to get upon the Bed, 
kneeling close by the Side of your Patient, with her Face to 
you, and put her Hands under the Bed-clothes (but at this 
Time only a Sheet covers the Patient unless very cold Weather) 
down to your Patient's Pubis, with the inner part of her Arms 
turned to yom' Patient's Belly, then with your Bight-hand 
feel externally for the Child's Head; and where the most 
proper Place is not exactly over the Pubis, but on each Side 
toward the Groin, there ^lk the Hind-part of the Palms of both 
her Hands upon the Child's Head, bidding her press dovni 
pretty strongly, you pulling the Child at the same time. 
. . . . By this Method, joined to that of giving the Child 
Air, experience has convinced me, that every operator wiU 
soon find the great Benefit of them, by saving a great many 
Children which otherwise would perish ; for by this Method 
of Turning and the Assistance of my cmwed Forceps when 
Turning was impracticable, I have not opened one Child's 
Head for upward of fourteen Years." 



CHAPTER YIII. 

POST-PAETUM HEMOKRHAG-E. 

Case : Post-partum hemorrliage. — Eemarks on post-partum hemorrhage. — Why 
tonic uterine contraction is desirable. — Treatment. — Ergot. — Hand in utero. 
— Cold. — Manipulation of the uterus. — Case: Foot, hand, and funis presenta- 
tion of second twin ; commencing inversion of the uterus rectified by manip- 
ulation. — Undue elevation of the fundus uteri a sign of danger. — Its causes. 
— Fatal post-partum hemorrhage does not necessarily flow out of the vagina. 
— Case: Albuminuria; post-partum convulsions; post-partum hemorrhage. 
— Case: Post-partum hemorrhage. — Why the placenta and membranes 
should be carefully examined. — How soon delivered. — How removed. — 
Indications for an ansssthetic. — Hemorrhage when the uterus remains con- 
tracted. — ^Position of patient. — Arteries. — Warmth. — Restoratives. — Ene- 
mata. — ^Anodynes. — The Dublin School. — Case: Tedious labor; forceps; 
novel views of uterine hemorrhage. — Transfusion. — Angemia. — Predisposi- 
tion to future post-partum hemorrhages. — Ergot for multiparee after labor. — 
Subsequent hemorrhages. — Case: Forceps; puerperal fever; bronchitis; 
death from uterine hemorrhage eleven and a half days after delivery. — Ob- 
stetric binder. 

Case 92. — Post -jpartum hemorrhage. — Dr. Forman^ 
House Surgeon. 

Alice Merwin, set. 20 ; U. S. ; married ; admitted to 
Bellevue, March, 1867, in the eighth month of her first preg- 
nancy. Labor commenced April 12, 1867, at 6 p. m., L. O. 
A. Membranes rnptm^ed at 1 a. m. on the 18th. The sec- 
ond stage was accomplished in two hours ; the pains during 
the early part were infrequent and feeble, but quite power- 
ful when the head reached the perineum. After the occiput 
had escaped and the head was being extended, there came a 
very violent pain, and the whole child was expelled in one 
expulsive efibrt, followed immediately by a gush of blood. 



224 OBSTETRIC CLINIC. 

The uterus was grasped bj tlie hand and forced down in the 
pelvis, but did not contract. Blood flowing freely from the 
vagina, | ss of the fluid extract of ergot was given. The 
cold douche and friction to the abdomen, with ice, were used. 
The fundus uteri firmly grasped with the hand, and ice 
passed into the vagina. After using these measures for a 
few minutes, the uterus contracted and expelled the placenta, 
but this contraction was only momentary, and after delivery 
of the placenta the blood flowed in a stream from the vagina ; 
the woman became pallid, restless, gasped for breath, and 
had an extremely anxious look. Pulse very weak, and so 
frequent that it could not be counted. Dr. Forman then in- 
troduced his hand into the cavity of the uterus, tm^ned out a 
mass of clots, and thus held the uterus by conjoined manip- 
ulation. As this manoeuvre had no effect, a piece of ice, 
the size of an egg, was carried up to the fundus, and the 
uterine wall rubbed with it. This almost immediately ex- 
cited contraction, when it, together with the hand and a 
mass of clots were expelled, and the hemorrhage ceased ; the 
woman meanwhile having fallen into, a state of syncope, 
from which she rallied, after her head had been well lowered, 
and her hmbs elevated above the level of her body. As soon 
as she was able to swallow, an ounce of whiskey was given, 
which she vomited, and then a hypodermic injection of thirty 
drops of Magendie's solution of morphia was given. The 
uterus remaining contracted for an hour, and all hemorrhage 
having ceased, a bandage was tightly applied, and the woman 
left asleep, in which condition she remained for several hours. 
Upon awakening, her pulse was 160 and very feeble. Or- 
dered absolute rest. Egg-nogg, one ounce an hour. Extra 
strong beef-tea. 

After the hemorrhage had ceased, the clots of blood lying 
on the bed under the woman were gathered up, and filled an 
ordinary tin wash-basin two-thirds full. The duration of the 
hemorrhage was about ten minutes. 

April 16th. — The patient has been kept moderately un- 



POST-PAETUM HEMORRHAGE. 225 

der tlie influence of morpliine, and lias taken all the nourisli- 
ment it was possible to administer. She is very anaemic, 
weak, and has a pulse of 150. 

May 1st. — The patient has been slowly and steadily im- 
proving in strength, but has lately had some bronchitis, and 
rheumatic symptoms in the left hand, and a swelling over 
the dorsum has been opened by an exploring-needle, discharg- 
ing serum, but no pus. The opening Avas closed at once, and 
the hand put on a splint. 

May 8th. — Thoracic symptoms relieved. Patient sitting 
up. Slst. — Patient can walk about the ward, and out on the 
balcony. The splint gave great relief, so much so that she 
would not allow it to be removed, and would replace it when 
removed by the attending physician, who repeatedly warned 
her of the risks of continued immobility of the joint. She 
has now some fibrous anchylosis. 

Jkdy 15th. — Passive motion has been faithfully kept up, 
with the eiiect of partially restoring motion. 

Septemher 20th. — Patient has nearly regained the perfect 
use of her wrist, and is perfectly well. Expresses regret that 
she would not bear the passive motion and withdrawal of 
splints when they were first recommended. 

Remarks on jpost-j)artum hemorrhage. — The case of Alice 
Merwin Q^o. 92) is a type of those so frequently met with 
in practice, and a striking illustration of the dangers which 
the student may be called on to meet in his first case of labor, 
and which he must be thoroughly prepared to encounter. 

It is my conviction that deaths from post-partum hemor- 
rhage, of the immediate variety from which Alice Merwin 
sufiered, rank among the most preventable causes of death ; 
and that the practitioner, responsible for the treatment, has 
the burden of proof thrown on him to show why the moth- 
er's life was not saved. 

Under these circumstances, the narrative of Dr. Forman's 
prompt and determined treatment may be read with advan- 
15 



226 OBSTETRIC CLINIC. 

tage, and may well serve as the basis of some practical sug- 
gestions. 

Why tonic uterine contraction is desirable. — As a clinical 
probability, we assign immediate post-partum bemorrhage, 
and after-pains, to the multipara, rather than to the primi- 
para ; and attribute both, with justice, chiefly to the relaxed 
and inefficiently contracted state of the uterus. As a rule, 
if the uterine muscular fibres are tonically contracted, they 
ligate the uterine sinuses, and prevent undue loss of blood; 
they squeeze out the amount of blood which the sponge-like 
distribution of the sinuses permits them to retain ; and thus 
it is undoubtedly true that if we could weigh the thoroughly 
contracted uterus in one woman just after confinement, and 
then weigh the relaxed uterus with the blood still in the 
sinuses of another, we would obtain a marked difference in 
the increased weight of the latter. Independently, there- 
fore, of the value of a contracted uterus as a prophylaxis of 
post-partum hemorrhage, and of the annoyance from after- 
pains, it is evident that such a condition places the uterus in 
a better state for the important processes of involution which 
so rapidly follow on delivery. On two occasions, I have 
found that the fatty degeneration of the uterine muscular 
fibre has commenced within twenty-four hours after delivery, 
and it is probable that the commencement of this return to 
the physiological condition of the unimpregnated uterus is al- 
ways rapid. It seems, therefore, to me that independently 
of the risks from hemorrhage, and the desirability of prevent- 
ing after-pains, tonic contraction of the uterus is most desir- 
able as a means of warding off hypersemic conditions, which 
cannot fail to increase the risks of those inflammatory sequelae 
of labor to which the uterus is liable. 

Treatment. — In the case of Alice Merwin, the cause of -the 
hemorrhage seems to have been relaxation of the uterus after 
a rather rapid labor for a primipara, with powerful expulsive 



POST-PAETUM HEMOEEHAGE. 227 

pains. Under these circumstances, the treatment offers an 
example of the graduation of remedies increasing in severity 
in ratio to the continuance of the flow. Ergot. — As soon as . 

possible give a reliable preparation of ergot in full doses jj 

freely. I always have this medicine ready for this purpose 
in every case of labor. Hand in utero. — It is a very good 
rule to abstain as long as is safe from the introduction of the 
hand in utero after labor, and especially in lying-in hos- 
pitals, for their statistics show an increased ratio of subse- 
quent puerperal inflammation after this procedure. Still 
where other and milder measures have proved themselves in- 
operative, he is the best practitioner who coolly and prompt- 
ly proceeds to those which remain. Cold. — There is a disad- 
vantage from the application of cold water in quantity to the 
abdomen, as the dress and bed-clothes are liable to be so 
wetted as to demand a change while the patient is yet ex- 
hausted from the flow, or expose her to other risks. The ether- 
spray instrument of Richardson might produce the amount of 
cold and shock desired without these inconveniences. For 
my own part, I have not poured a column of water on the 
abdomen for many years, as I flnd that a lump of ice held in 
the hollow of the hand over the fundus, with ice in the va- 
gina, and possibly in the rectum, have sufficed. And while 
I have often carried ice to the cervix uteri, it has never been 
necessary in my practice to carry it within the cavity of the 
womb. 

Manipulation of the Uterus. — It is undoubtedly the fact 
that post-partum hemorrhage can be prevented in a large 
proportion of cases, by the skilful control of the uterus 
maintained by the hand placed over the fundus, while the 
child is passing into the world, and retained there until some 
time after delivery of the placenta. 

I never omit this practice in my own cases, and when 
obliged to remove it temporarily for the separation of the 
cord, or delivery of the placenta, etc., I satisfy myself that 



228 OBSTETEIC CLLS^IC. 

the hand of another person is properly applied, and grasping 
the nterus, dming the interval. 

Generally speaking, after delivery of the placenta, I pre- 
fer to retain my hand over the fundns until the baby has 
been washed and dressed, before applying the bandage. 

This manipnlation of the nterus is fatiguing, and I 
have very frequently known it to be conscientiously per- 
formed in a bad manner. In the first place, force is not 
necessary ; in the second, the uterus must not be flattened, or 
pushed to one side. The ulnar border of the hand should dip 
down somewhat behind the fundus, the fingers should lightly 
estimate the contraction on the left side of the uterus, and the 
wrist is soon taught to estimate the condition of the right. 

In the following case this manipulation warded off one 
of the most dangerous post-partum complications, remedi- 
able in direct ratio to the early date of interference : 

Case 93. — Foot^ hand, and funis presentation of second 
twin J commencing inversion of the utei^us rectified hy mani2> 
ulation. 

Mrs. , aged 30, primipara, pregnant with twins, was 

delivered of a living male child after a labor rendered tedi- 
ous by great inertia of the uterns, and for which large doses 
of ergot had been given. I was sent for by the two phy- 
sicians in charge, to deliver the second child. I found that 
great efforts had been made to deliver the placenta after the 
birth of the first child, and that the cord had been torn away. 
The vagina was somewhat lacerated. The hand and foot of 
the second child were in the vagina, enclosed in a caul and 
swollen, and a pulseless funis could be reached. The use of 
an anaesthetic was objected to by the physicians in attend- 
ance, and 1 readily delivered a good-sized stiU-born male 
child by pushing up the arm and drawing on the foot. The 
placenta came away readily, and showed the place where 
the first cord had been torn away. 



POST-PAETUM HEMOEEHAGE. 229 

A very free flow of blood followed the placenta, and 
tlirongli the thin and relaxed abdominal wall I recognized 
that the fundns nteri was deeply cupped. Carrying two 
fing-ers at once within the nterns to the fundus, with the 
other hand over the abdomen, I very readily coaxed and 
manipulated it into shape, when it contracted firmly, the 
hemorrhage ceased, and the woman did well. 

Undue elevation of the fundus uteri a sign of danger ; 
its causes. — The degree of elevation of the fundus is a point 
of importance, for if this be too great something is wrong, and 
there is risk of trouble, even if the contraction be good. In 
these cases I have always enforced attention to the bladder. 
If this be distended, let it be emptied at once, so that the 
uterus may sink into the pelvis, and have the strain removed. 
If the bladder be empty, then make a careful vaginal ex- 
amination for clots or for portions of retained placenta. 

While writing these pages I saw a patient in consultation 
with an experienced and skilful friend, on account of recur- 
ring attacks of syncope, with very moderate post-partum 
hemorrhage. The uterus was well contracted, not much 
enlarged, if any, but the fundus reached nearly to the um- 
bilicus. As the physician had made a careful examination 
of the placenta (which he had been obliged to remove for 
adhesions), and had satisfied himself that none had been left 
behind, and as his last vaginal examination had detected no 
clots, I requested him to use the catheter, notwithstanding 
tke patient's statements that she had just passed water. The 
bladder was found empty, and so I wondered whether in- 
creased pelvic obliquity, or some other anatomical peculi- 
arity might explain this exception to what I have so long 
taught as a law. But in the afternoon some moderate 
hemorrhage recurring, and a vaginal examination being re- 
quested, a large portion of placenta was found still in utero, 
and partially adherent. As much as could be removed 
was taken away, and a portion still left in situ near the os 



230 OBSTETEIC CLINIC. 

uteri, about the fate of which we felt uneasy for some days, 
finally came away, and the patient did well. When the re- 
moval of the greater part was efi'ected, the uterus came down 
to its proper place, and asserted the supremacy of the law — 
that an unduly elevated uterus after delivery is a source of 
anxiety and risk, and that if it be noticed, the catheter should 
be used, and a careful vaginal examination always made. 

Fatal post-jpartum hemorrhage does not necessarily flow 
out of the vagina. — Women may bleed to death without the 
torrent gushing from the vulva. Large clots in the vagina 
may act as tampons, and both conceal and facilitate the 
uterine hemorrhage. 

Case 94. — Albuminuria^ ])os1ypartum eclampsia ; ;post- 
jpartum hemorrhage. 

Dr. called me to Mrs. , a multipara, who had 

been attended by a German midwife. She had subsequently 
suffered from eclampsia and hemorrhage, for which the 
doctor had been called, and after insuring good uterine con- 
traction, and giving brandy by enema, he came for me. 
Her pallid, ansemic look struck me more forcibly than her 
unconscious condition, though there were no traces of blood 
in the bed. On examining the abdomen, however, I found 
the fundus of the uterus above the umbilicus, and the womb 
filled with clotted blood, which was readily taken away, 
when a small portion of retained placenta was found. After 
the customary measures, position, brandy, ergot, and beef-tea 
had rallied the patient's strength, I left. She was still un- 
conscious. There was no other oedema than in the legs. 
Urine drawn with a catheter, and found to be very albumin- 
ous. I am informed that she died a few days afterward. 

Case 95. — Post-jpartum hemorrhage. 

A patient of mine, subject to post-partum hemorrhage, 
was confined during my absence, and was attended by a 



POST-PAETUM HEMOEEHA&E. 231 

professional friend. I arrived at the house just after the 
bandage had been applied, and meeting him in the hall, 
requested him to give the patient a full dose of ergot before 
leaving, as I was sure that she ought to have the medicine, 
and it was better that he should order it. He laughingly 
declined, and on entering the room the report was made by 
the nm'se that all was going well, but the expression of the 
patient's countenance was unfavorable, and the uterus as 
high as the umbilicus, and although there was no external 
hemorrhage, I turned out a quantity of clots which half-filled 
a large wash-basin, and was obliged to resort to very active 
measures to procure contraction and revive the patient, 
who had become unconscious before my task had been com- 
menced. Dr. Edward Delafield saw her in consultation 
with me, and she recovered. 

WTiy the placenta and membranes should he carefully 
examined, — It is evident from one of the cases just detailed 
that a very good practitioner may examine a placenta carefully, 
and believe that all has been removed, while yet some remains ; 
a fact which should stimulate us to make a very careful 
examination of that organ in every case, and never to neglect 
a study of the membranes as well. I have seen a portion of 
the membranes left in utero in two autopsies of women dy- 
ing suddenly after labor from other causes ; and I know that 
the beginner may find it a task of no little difiSculty to sat- 
isfy himself that he has fully removed portions of slippery 
membranes broken from the placenta, and left within the 
vagina. The best way is to twist them into ropes, if possible, 
and if they be within the cervix to twist and draw in the 
direction of the superior strait, as though you were trying to 
carry them back through the middle of the sacrum. 

The placenta succenturia, a supernumerary, or slightly 
attached portion of a placenta, may be left behind unwit- 
tingly, as we have no right to assume its existence. 

Hovj soon delivered, — In such cases as that of Alice 



232 OBSTETRIC CLINIC. 

Merwin, it is better that tlie placenta sliould be promptly 
remoYecl, as a step to the permanent contraction of the nteras ; 
and nndoubtedly it is both better and more satisfactory that 
the placenta should always come away, or be made to come 
away, within a quarter of an hour after delivery of the child, 
nnless in exceptional cases. Bnt there is no Procrustean bed 
in the practice of medicine. Experienced and inexperienced 
men cannot be forced to adapt themselves to absolute uni- 
formity of practice. In this, as in all that is elective, there 
is an esoteric and an exoteric school, and the beginner must 
not assume the liberty of action which becomes the expert. 

How removed. — Still, if the uterus has been well manip- 
ulated, and the placenta be not adherent, or retained by 
irregular uterine contractions, or if the uterine bulk be not 
increased by clots, or by a very large placenta, the latter 
will in the great majority of cases be recognized by the 
touch, hanging over the anterior lip of the uterus, and 
partly in the vagina. In these cases, by aiding the next 
uterine contraction with a rather firm pressure, concen- 
trically applied (if the expression be permitted) so as to sim- 
ulate the uniform uterine contraction, and if the placenta be 
gently drawn or pushed with two fingers carefully in the 
du-ection of the superior strait, the delivery may usually be 
effected by a method not open to any serious objection, and 
within the control of all. 

Indications for an anoestheUc. — ^If adhesions or irregular 
uterine contractions retain the placenta, and the hand must 
be passed in utero, then it is always better to give chloroform 
or ether before commencing ; unless serious hemorrhage, or 
syncope, or great debility, or other contra-indications exist. 
Those who have delivered placentae under these circum- 
stances with anaesthetics and without them, will indorse the 
recommendation. You may have to pass the fingers well 
within the uterus to the fundus, and through the abdominal 



I 



POST-PAETUM HEMORRHAGE. 233 

wall Yoii feel tliem at tlieir work witli tlie liand wliicli is on 
the abdomen and steadies the nterus in the task. The anses- 
thetic is not only to be recommended for its advantages in 
facilitating, shortening, and insuring the extra-uterine manip- 
ulation, it also saves the mother the mental shock of sustain- 
ing so severe a procedure when she had with good reason 
hoped that her trial had di'awn to an end. It prevents her 
from recalling on the morrow, with a shudder, the painful 
and tedious manipulation which may have been demanded. 

Hemorrhage when the uterus Temains contracted. — It 
will happen sometimes that there may coexist great uterine 
hemorrhage with a contracted uterus. If the uterus be really 
empty and there be no inversion, then we may suspect that a 
laceration of some maternal tissue* has implicated a vessel, or 
that a thrombus has formed and ruptured. Thrombi are 
infrequent, and are readily recognized as a law by careful 
examination. Some patients, with enormous varicose veins, 
whom I have attended in labor, have made me apprehen- 
sive on this score, the vulva feeling enlarged, and like the 
scrotal varicocele in the male. But the recumbent position 
saves these vessels from strain, and they have never given 
me any trouble, nor have the two cases of vaginal thrombi 
under my observation resulted in serious harm. But the 
blood may come from a vessel spurting in the torn perineum, 
from the lacerated cervix, or torn vagina. Two cases of 
hemorrhage from vessels in the perineum have occurred 
within a few years in Bellevue, and in each the vessel was 
readily seized and the bleeding stopped. It is only in the 
case of hemorrhage from a large and opened thrombus, that 
a tampon would ever be necessary for a post-partum (imme- 
diate) hemorrhage, and then it is very unlikely that any case 
could be found that would not yield to cold and firm pressure 
of hnt or cotton dipped in the persulphate of iron. 

Position of patient. — With the use of the measures for 



234 OBSTETEIC CLIOTC. 

controlling tlie escape of blood, those should be simnltane- 
ouslj conjoined wliicb keep tbe residue in tlie brain and 
thorax, and favor the prompt manufacture of more. These 
are equally indicated in all cases of dangerous uterine hem- 
orrhage. 

All manoeuvres connected with the delivery of the pla- 
centa and management of the uterus can be readily used 
while the patient's knees are held high up in the air, and the 
pelvis even partly lifted from the bed. The arms can be 
held up, and the head thrown well down below the level of 
the trunk if necessary. 

Arteries I warmth i restoratives. — The abdominal aorta 
and the brachial arteries can be compressed, the window 
opened, water dashed on the face, strong restoratives ap- 
plied to the nostrils, while the important work with the 
uterus is going on. And the practitioner should be alive to 
the desirability of keeping up the patient's warmth. She 
should not be uncovered ; she may need bottles of hot water 
around her person. 

Enematci. — Though she should be unconscious as the 
dead, she can have enemata of strong beef-tea and whiskey, 
or brandy, thrown into the rectum, and held up by pressm-e 
against the anus with a folded towel, until they are safely 
retained. Nowadays Borden's extract of beef enables us to 
prepare the tea in a moment, and of excellent quality. And 
indeed these enemata are valuable for other reasons. You 
can throw more up, and a greater quantity of brandy. There 
are not the same risks that nomishment may not be acted 
on, and become oppressive, as exist when it loads the para- 
lyzed stomach. The stomach under these circumstances is 
peculiarly liable to sympathetic vomiting, which, while it is 
apt to be associated with renewed uterine contractions, still 
costs the patient the food which she has been made to swal- 
low. And indeed I have often known the undigested mass 



POST-PAETUM HEMOREHAGE. 235 

to be thrown off by tbe stomacli many hours after it was 
hoped that it had done its work. If the food be not digested 
it becomes an oppressive foreign body, and adds to existing 
prostration. The rectnm, therefore, should be made to receive 
the bulk of the food in these distressing cases. 

Anodynes. — After time and the measures discussed have 
brought about tonic uterine contraction, and the pulse shows 
that danger of immediate death is over, great restlessness, jac- 
titation, and mental anxiety often remain. If the patient 
should not soon be composed by a natural sleep, then an ano- 
dyne is indicated. Here, again, I prefer to pass a suppository 
into the rectum, or to give an anodyne by the mouth, rather 
than to use hypodermic injections. The latter, however, have 
the great advantage of being immediate in their effects ; but 
the dose must not exceed ten drops (five are better) of Magen- 
die's solution, until time has thoroughly shown that there is no 
danger of an overdose, or of producing a cumulative "action. 

The Dublin School. — My note-books contain a history of 
the impression made on my mind by the methodic, system- 
atic, cool treatment of a bad case of post-partum hemorrhage 
that occurred in a patient under my care while a resident 
pupil in the Dublin Lying-in Hospital, in 1849 ; Drs. Shekle- 
ton and Johnston saving a woman from what seemed impend- 
ing death as certainly as though she had been saved from 
drowning ; and while the profession is indebted to that school 
for the spread of the best principles of preventing post-partum 
hemorrhage, it is certain that in 1867 the rules will still 
bear to be kept — as we say — before the people. 

Case 96. — Tedious labor ; forcejps • novel views of ute- 
rine hemorrhage. 

In the year 1859 I was sent for to Yorkville, to deliver a 
woman who had been in labor two or three days, and took 
with me my friend Dr. Eeuben Cobb, of l^orth Carolina, then 



236 OBSTETRIC CLINIC. 

one of the liouse physicians of Bellevue. We found the pa- 
tient under the care of a midwife, in a deplorable condition, 
with green vaginal discharge, and greatly swollen vnlva, bnt 
with the foetal heart andible. The head was in the superior 
strait, with the movement of descent not yet completed. Dr. 
Cobb brought the patient under the influence of chloroform, 
and I delivered her of a living child, which did well, as did 
also the mother. 

Before lea^dng, I took the midwife into another room, to 
ask what she would do if flooding were to occur. With much 
blarney, and approval of my operation, she replied : " Sm-e, 
darlint, and I niver fear that at all at all. I just goes into 
the garden, and takes a bit of clay about as large as the 
palm of my hand, and puts it on the pit of the stomach, in 
the name of the Father, Son, and Holy Ghost." 

Seeing that this act of simple faith was all that the poor 
woman had to rely on, we thought it advisable, as the days 
of mii'acles were passed, to administer a good dose of ergot 
before leaving. 

Transfusion. — In all the cases that I have seen, the 
question of transfusion has only come up on two occasions. 
Once it was performed at the Hopital St. Louis by ^N^elaton, 
in a case of placenta prsevia, saving the patient's life for the 
time, though she subsequently died fi-om metro-peritonitis ; 
and once in this city. In Paris my friend Dufour, then 
Cazenave's interne, furnished the blood, and this being lost 
by the agitation of an assistant, a second supply was taken, 
and received directly in a syringe previously warmed. 

Dr. Bronson, of this city, asked me to see a primipara 
with him for post-partum hemorrhage. This had been en- 
tirely controlled before my arrival, nor did any take place 
afterward, the uterus remaining contracted and empty, and 
the vagina free from blood. But she continued to sink, and 
could not be rallied, although she was conscious. Dr. W. H. 
Yan Bm-en then saw her, and was prepared to transfuse, but 



POST-PAHTUM HEMOEEHAGE. 237 

it is sad to relate that the husband refused to furnish the 
blood, or even to allow transfusion to be performed on the 
joung wife, who was bidduig him the most aifectionate fare- 
well with her last breath. 

Ancemia. — If these patients escape the peril of their posi- 
tion, and the risk of heart-clot, there remains for them the 
certainty of ansemia, which may occasionally affect the con- 
stitution for life, and always demands iron and a roborant 
treatment. 

Predisposition. — They may develop an increased liability 
to post-partum hemorrhage in the next confinement, re- 
quii'e additional pro|)hylactic treatment, and more careful 
watching. 

Ergot for muUijparcE, — It is my custom in Bellevue, for 
these and the preceding considerations, to direct that all the 
multiparse in my service shall receive a full dose of ergot 
after labor ; and such is my custom in private practice, un- 
less- in very exceptional cases. 

Subsequent hemorrhages. — Unfortunately, immediate post- 
partum hemorrhage is not all the risk. The subsequent, or 
secondary ones, prominently acknowledge as causes retained 
portions of placenta, membranes, and clots; or ulcerations 
of the cervix, or vaginal tissues, possibly involving a vessel; 
or undue exertion. But sometimes the hemorrhage may 
come, and may cost the patient her life, and without an au- 
topsy we may remain ignorant of the cause, as in the follow- 
ing case. 

Case 97. — Forceps ; puerperal femr ; bronchitis ; death 
from uterine hemorrhage eleven days and a half after de- 
livery j child did well. — Bellevue Hospital — D7'8. J. R. 
Buist and George 8. Hardaway, House Physicians. 

Mary Conroy, aged 26, unmarried, fell in labor at 5 a. m., 
October 28, 1857. The second stage had lasted eighteen 



238 OBSTETEIC CLESriC. 

lioiirs, and during tlie last fifteen the head was retained in 
the brim by the promontory. The pains were and had been 
efficient, head in first position, olive-green discharge from 
the vagina, foetal heart beating very rapidly. 

Under these circumstances Dr. Buist sent for me, and the 
woman having been brought under the influence of chloro- 
form, I delivered her with forceps of a living child, weighing 
ten pounds, which subsequently did well. 

October Z\st. — Until to-day the woman's condition has 
been satisfactory ; but now lochia are suppressed, abdomen 
tender, face flushed, pulse frequent, tongue moist. Warm 
fomentations ordered to vulva. Turpentine stupe to the 
abdomen. 

Novemtev 1st. — Chill. Pulse 135, skin hot and dry. 
Quarter of a grain of the sulphate of morphia and ten drops 
of the tincture of the veratrum viride every two hours. 

November 2d. — Better in forenoon, but worse in afternoon. 
Transferred to the fever ward, service of Dr. McCready. At 
this time she had a dusky flush of face, pulse 140, respira- 
tion 36, and thoracic, tongue dry and coated brown, abdomen 
immensely distended, and very tender to the touch, lochia 
very foetid, no secretion of milk, lips dry and cracked — 
sordes on both, and loose, green discharges from the bowels. 
Ordered opium one grain, quinine two grains every two 
hours, with ten drops of the tincture of the chloride of iron 
at the intermediate hour. Whiskey | ss every hour. Diet, 
beef-tea and boiled eggs. 

November Zd. — Tongue not so dry, otherwise condition 
about the same ; blister 6 by 8 applied to abdomen, and then 
dressed with mercurial ointment. 5 p. m. — Pulse 134, tongue 
moist, diarrhoea checked. 

Noveinber Uh. — Forenoon ; pulse 130. Does not like the 
whiskey, Madeira wine substituted. 6 p. m. — Pulse 140, 
tongue dry, no lochial discharge, 3 ss wine every half hour. 

Noverriber bth. — Pulse 124, respiration 26, tongue dry, 
very restless, wanted to sit up, slightly ptyalized. 6 p. m. 



P03T-PAETTJM HEMORRHAGE. 239 

— Piilse 140, nates and lower part of back red, and much 
iiTitated, as tliongli bed-sores were about to form. 

November ^th. — Something better, wine not good, brandy 
in its stead, 3 ss in milk every hour. Reddened skin painted 
with collodion, simple cerate substituted for the mercm'ial 
ointment, other treatment continued. 

Novemler ^ith. — Pulse 124, tongue dry. 

November Sth. — Pulse 128, patient does not look so well, 
has considerable bronchitis. Turpentine stupes to chest ; 
other treatment continued. The natural lochial discharge 
has reappeared. 

November ^th. — Pulse 124, tongue dry, respiration nat- 
ural, patient looks better, bowels opened for the first time in 
two days. In the afternoon the lochial discharges became ra- 
ther free, though not considered as an unfavorable symptom. 
4.40 p. M. — Dr. Hardaway sent for, as the patient had a chill. 
Pulse 200. 5 p. M. — Pulse 180. Tinct. veratri viridis, gtt. 
X. 6.30 p. M.— Pulse 140; v. v. gtt. x. 7.30 p. m.— Pulse 
124. Tinct. veratri viridis, gtt. x. 8.30 p. m.— Pulse 128 ; 

V. V. gtt. X. 

8.45 p. M. — Dr. Hardaway was hurriedly called from his 
room, because blood was seen to drop from the patient's bed 
on the floor. She had made no complaint nor spoken to her 
neighbor in either bed, and was blanched and pulseless be- 
fore Dr. Hardaway could reach her side, and died almost 
immediately, though he had instantly ascertained that the 
hemorrhage was uterine, and had plugged the vagina. 

Olstetrio binder. — A diversity of opinion exists regard- 
ing the application of bandages after labor, and the question 
is more important in its relations to post-partum hemorrhage 
than to any thing else. Many of those who believe in the de- 
sirability of applying bandages snugly, aim to accomplish 
the result by inserting compresses of various shapes and 
methods beneath the obstetric binder ; and every now and 
then a new form of bandage is devised, and pictured in the 



240 OBSTETRIC CLINIC. 

books. Those who do not use the binder support their views 
by arguments against its necessity, and by such as claim that 
more harm may be done to the sensitive tissues by pressure, 
than by allowing them to remain unconfined. In my prac- 
tice I have taken care of patients who have been confined, 
with and without the subsequent use of the binder, and they 
generally prefer one well applied. 

ISTow, in my opinion, unless a bandage is properly se- 
lected and fitted, it is liable to do harm rather than good ; 
and it is my conviction that as they are often applied they 
are inefi*ectual, and may do harm. But the abuse is no argu- 
ment against the use, and I believe that a patient may be 
rendered more safe and more comfortable with a bandage 
than without one. The important results to be obtained oc- 
cur during the first few hours which follow delivery ; after 
that time, bandages are more matters of convenience than ne- 
cessity, and need never be applied as snugly. I never use 
compresses at all, and my experience in observing their situ- 
ation in the cases which I have seen in the practice of others, 
for many years, teaches me, that while I have often seen them 
applied with the greatest tact, and answer every desired indi- 
cation, they are often liable to slip out of place, and produce 
other effects than those intended. They may compress the 
uterus against the back part of the pelvis and lowest verte- 
brge, and push it to one side, and the condition of the uterus 
cannot be as well appreciated through their folds. In cases 
of hemorrhage, and in cases of bad after-pains, where it has 
been necessary for me to examine them, I have often found 
this hurtful state of things. 

On the other hand, a bandage of straight muslin, wide 
enough to be securely fastened below the great trochanters, 
and to pass up to the floating ribs, is not liable to slip, if the 
first pins be tightly applied at the lower margin, and the pins 
then pass upward and near together. Meanwhile, a hand 
holds the fundus uteri lightly in its hollow, and as the pins 
approach, the hand is removed when the bandage is snugly 



OBSTETEIC BINDEE. 241 

drawn, and as tightly fastened as the woman can com- 
fortably bear it, just above tbe fundus uteri. The bandage 
thus has two principal features — a secure hold below the tro- 
chanters ; a secure hold above the fundus ; and this pressure 
takes the place of the hand which has up to this time manip- 
ulated the uterus. Often in women rather thin, the outline 
of the uterus can be seen beneath the well-adapted binder, 
and it can be readily felt if it be contracted, without disturb- 
ing the bandage. Otherwise, it is time to seek for the womb, 
and study its condition. 

Such a bandage meets all the indications; giving that 
comfort derived from a bandage after tapping, and diminish- 
ing the risks of hemorrhage. But if it be improperly adjusted 
so as to flatten and compress the uterus, and pain the woman, 
she would be better off without it. The wide-spread con- 
viction among women, that a well-applied bandage assists 
the restoration of their figure to the desired outlines, is not an 
argument for its use. 

In cases where I have special cause to apprehend metritis, 
or other inflammatory sequelae of labor in hospitals, I often 
order a good flannel bandage, or a broad apron of oiled silk 
to be applied beneath the bandage, as a comforting and 
prophylactic poultice which does not need to be changed ; 
an important point in hospital practice. 



16 



CHAPTEK IX. 

OBSTETEIO OPERATIONS IN DEFOEMED PELVES. 

Case: Contracted conjugate diameter in a primipara; forceps. — Case: Con- 
tracted conjugate diameter in a primipara; forceps. — Case: Transverse 
presentation in a contracted conjugate diameter ; cephalic version ; perfora- 
tion ; cranioclast ; death of child from premature respiration. — Case : Rachi- 
tis ; contracted outlet ; forceps. — Increasing frequency of pelvic deformity 
in this country. — ^The same deformity admits of vai-ying results in successive 
pregnancies. — Case: History of successive pregnancies in a patient with 
contracted conjugate. — Can these measurements be accurately made? — 
Case : Deformity of pelvis ; albuminuria ; forceps and version failing, deliv- 
ery effected by craniotomy and the cranioclast ; accurate measurement of 
pelvis by Earle's pelvimeter; pneumonia and metritis. — Pelvimetry. — Diffi- 
culty in estimating the size of the foetal head. — Remarks on the ulcerative 
perforation of the uterus and bladder in Case No. 94. — Case: Deformed 
pelvis ; forceps ; death from perforation of the uterus by sacral promontory. 
— Case: Contracted pelvic brim; forceps; vesico-vaginal fistula. — Case: 
Arrest of head by promontory of sacrum; forceps. — Case: Forceps for con- 
tracted brim. — Case: Forceps in superior strait. — Case: Rigid os and 
lingering first stage ; douche; forceps within the brim. — Case: Forceps for 
febrile symptoms in an epidemic of puerperal fever. — Case: Forceps for 
delay. — The proper time for operating in cases of delayed or obstructed 
labor. — Delivery of the head through the pelvic brim with forceps. — li it be 
even possible that the child is living. — Henry VIH. and Napoleon I. — This 
operation sums up all the difficulties with forceps. — Room for instruments 
may be obtained by pushing up the head, and the head may be steadied 
against the brim. — Case : Forceps above the brim. — Case: Pelvic presenta- 
tion in an undersized pelvis ; room singularly obtained for forceps. — The 
bead may be made to engage by external manipulation. — Case : Forceps in 
an undersized brim. — Case: Occiput pressed against the linea ilio-pectinea 
and rotating froni the left acetabulum to near the right sacro-iliac synchon- 
drosis ; made to engage by manipulation. — Case: Ante-partum hemorrhage; 
rotation of head before it engaged in the brim ; forehead presentation con^ 



OBSTETEIC OPEEATIOl^S IN DEFORMED PELVES. 243 

verted by the hand into that of occipital ; previous pressure of the head 
into the brim by the hand. — The head may be made to engage in the brim 
by altering the mother's position. — Case: Movement of descent brought 
about by changing the position of the mother. 



Case 98. — Contracted conjugate diameter in a primi- 
para / forcejps. — Dr. D. McLecm Forman^ House Burgeon. 

Maiy Kennedy, unmarried, primipara, aged 28, born in 
Ireland, was admitted to Bellevue Hospital April 7, 1867. 
Has always been bealtby, seems well formed, urine not albu- 
minous. Last menstruation June 25, 1866. According to 
her account the labor-pains commenced on the afternoon of 
tbe 5tli, were very violent during the night, diminished in 
frequency and severity during the next day, but recurred 
with great violence during the night, and subsided some- 
what toward the morning. When admitted to the hospital 
the pains recm-red about twice in an hour, and lasted a very 
short time. The patient's general condition was good in 
every respect. Yagina moist, and of normal temperature, 
OS uteri dilated to the size of half a dollar, head presenting, 
membranes had ruptured, according to the patient's state- 
ment, On the preceding night. The head was above the 
brim, foetal heart distinct a little below and to the left of 
the umbilicus. A Dover's powder was given, and the patient 
rested well through the night. 

Ajpril %tli. — Pains infrequent and feeble. Condition of 
the woman satisfactory. In the afternoon Dr. Elliot's atten- 
tion was called to her when he made his visit, and he recosr- 
nized that the conjugate diameter was contracted. Still by 
pressing the head between one hand placed above the pubes 
and the fingers of the other introduced in the vagina, he 
thought that there would be sufficient room if the pains 
were strong, and therefore directed uterine catheterization. 
A piece of a ITo. 8 India-ru.bber flexible catheter was intro- 
duced in utero and left in situ. Pains were soon awakened, 
and the catheter was expelled in one and a half hours. The 



hm 



244: OBSTETEIO CLIXIC. 

pains continuing to act with force, the os gradually dilated, 
and the position of the head could be recognized, viz., occi- 
put to the left ilium. After a few hours they began to de- 
crease in frequency, when they were revived by a stimulating 
enema. The patient's condition being good in every other 
respect than the delay of the labor, she was left to the care 
of the chief nurse with du^ection to summon Dr. Foiinan as 
soon as the head descended. 

Ajyril 9)th. — On visiting the patient in the morning. Dr. 
Forman found her tired, but not suffering much. Yagina 
still moi-st, OS uteri fully dilatable, and Dr. F. thought that 
the head had made some advance. Uterine contractions 
still present, but not very powerful. He concluded to wait. 
But by Dr. Elliot's ordinary visit, some hours later, her con- 
dition had become unfavorable. Eestless, exhausted, pulse 
frequent, uterine pains had almost ceased, vagina hot, 
discharge offensive, and olive-colored. Dr. Elliot found that 
no advance had been made, the supposed advance l)eing due 
to the development of the caput succedaneum, which was 
very large. The woman was now brought under the influence 
of an anaesthetic, and the pelvis more carefully examined. 
Passing the finger around the arc formed by the caput succe- 
daneum and parietal bone, the promontory was readily felt, 
and the conjugate estimated at three and a half inches. The 
perineum was somewhat rigid, and the vulva not large, and 
so Dr. Elliot decided not to use instruments to make a 
more accm-ate examination, on account of these facts, and 
the woman's condition, which called for immediate relief. 
Believing that the head could be delivered by the forceps, he 
applied them immediately without difficulty; but it was 
only after being driven to move up the pivot and make con- 
siderable compression, and by bringing all his strength to 
bear, that he was enabled after powerful efforts to pull the 
head past the obstruction. Once past this — a fact almost as 
readily recognized by those present as by himself — the re- 
maining steps of the delivery through the inferior &trait were 



OBSTETEIC OPEEATIONS IX DEFORMED PELVES. 245 

promptly accomplislied. The child (a girl) was born alive, 
but showed traces of the pressure which had been found in- 
dispensable for its delivery. Forty hours afterward it died. 

April 12th. — The woman has had no unfavorable symp- 
toms since her delivery, and is now doing well. She left the 
hospital in May, in good health. 

Memoranda of autopsy of cJiild hy Dr. Janeway^ Assist- 
ant Curator. — Female child, well formed, two days old. 
Surface congested. Excoriation on right cheek. Left side 
of skull considerably depressed by a groove which ran down 
the parietal bone, by the coronal suture from the anterior 
fontanelle to the base of the skull. {Mem. — This was pro- 
duced by the promontory.) On removing the skull-cap a 
large clot of blood was found lining the cavity of the arach- 
noid, and corresponding to the right parietal bone, and to 
the middle fossa of the base of the skull on the right side. 
There appeared a few ecchymotic spots on the posterior and 
superior part of the left hemisphere. On removing the brain 
a clot two inches by one escaped from the posterior and 
superior portion of the left hemisphere, where it had made 
for itself a cavity, about one-quarter of an inch below the sur- 
face. There were several points of ecchymosis around this 
cavity. The ventricles contained a small amount of serum, 
and a small clot was found under the lining membrane of 
the right lateral ventricle. The lower lobes of both lungs 
were in a state of atelectasis, and some patches were found 
in the upper lobes. Heart normal ; ductus arteriosus per- 
vious, and of large size. Liver weighed 3 iijss. Cells fatty. 
Kidneys each one ounce. Spleen normal. Brain tissue ex- 
amined microscopically, and the vessels appeared perfectly 
healthy, but in the brain substance were a large number of 
compound granular corpuscles. 

Case 99. — Contracted conjugate* forceps. — D. I. C. 
Mead, House Surgeon. 

Eliza Ford, aged 38 ; primipara ; admitted to Bellevue 



24:6 OBSTETEIC CLIXIC. 

May 4. 1S67. in the afternoon. At 6 p. m. the os uteri barely 
admitted the index finger. May o^A, 12 ^i. — Os fully dilated, 
membranes protniding. 2 p. M.^^Membranes ruptured. As 
the labor did not advance, Dr. Elliot was sent for in the eve- 
ning, and arrived at half-past eight. Dming this interval 
the pains had become good, and advance was being made. 
Pulse good. FcKtal heart distinct in the left iliac region. 
Dr. Elliot recognized a left occipito-iliac transverse position 
of the head, and diagnosticated deformity of the brim from 
jutting forward of the promontory. Still, as the head was 
advancing, and he estimated that the defonnity did not pre- 
clude the passage of the head, he left, after requesting that 
he should be notified if necessary. The pains and the foetal 
heart continued good dming the night, but the head made 
little advance, and Dr. Elliot was sent for at Y a. m. May 
6th. He arrived at S.15 with Dr. I. E. Taylor. The caput 
was found to have increased, but the head had not advanced. 
It was not impacted at all; was readily moved above the 
brim, and the operation of version quite feasible and elective. 
The foetal heart was audible. It was decided to deliver 
with forceps, and the bladder having been emptied, the fii'st 
blade was readily applied in front of the left sacro-ibac syn- 
chondrosis, and the second behind the right acetabulum. The 
pivot was carefully adjusted so as not to allow compression, 
and the fullest eflPort made with the forceps as tractors, but 
without effect. Accordingly, it was decided to make com- 
pression also, and a pair of long, straight forceps employed. 
These were promptly applied_, compression made, and the 
child delivered. As careful auscultation failed to detect the 
faintest tlu'ob of the child's heart, efforts at resuscitation were 
abandoned. The placenta came away readily, the patient 
came promptly and satisfactorily from under the influence 
of the sulphm'ic ether, and a fuU dose of ergot was given. 
6 p. :si. — ^A^omitiug. Hypodermic injection of moip)hine. 
May 1th, 10 A. M. — ^Pulse 130. ^^o pain over the abdomen. 
6 p. M. — ^Pulse 122. Eespiration 36 and thoracic. Tender- 



OBSTETEIC OPEKATIONS IN DEFOEMED PELYEg. 24:7 

ness over uterus and abdomen. Lochia small in amonnt, bnt 
natm*al in color. Continual dribbling of nrine. Turpentine 
to abdomen. Hypodermic injection of morphia. May Sth, 
— Transferred to tlie medical wards. 10 a. m. — Pulse 128. 
Eespiration 40 and thoracic. Tenderness over uterus and 
abdomen. Breath peculiarly sweet. Skin moist. Lochia 
scanty, but natural in color. Urine dribbles still ; -Qye ounces 
drawn by the catheter. From this time the pulse ranged 
from 120 to 140; respiration 20 to 26. She continued to 
sink, and died on the 9th at 11 p. m. While in the medical 
wards the catheter was passed on one occasion, notwith- 
standino; the dribblino; of the nrine, and about half an ounce 
of urine was obtained. This contained albumen and some 
fatty casts. 

Autopsy of child six hours after death^ 'before the Class. — 
1^0 injury to scalp or face. Traces of forceps visible. The 
scalp having been incised over the fronto-parietal suture and 
stripped back, blood was seen oozing from an opening in the 
posterior part of the longitudinal sinus, l^o blood had been 
extravasated there, and it was supposed that the injury had 
been inflicted at the autopsy. Due consideration given to 
the question of possible laceration by the eversion of the 
superior edges of the parietal bone during compression of the 
head. The brain was markedly congested, and a good-sized 
clot was found in the cerebellum, around which the brain 
tissue was softened and broken. The thoracic organs were 
normal, lungs uninflated, serum in pericardium. Thymus 
healthy. On opening the abdomen a considerable quantity 
of straw-colored serum poured out. The amount was not 
sufficient to cause any distension of the abdomen. At first 
sight the peritoneum appeared healthy, but further examina- 
tion showed that some of the intestinal coils were slightly 
adherent to each other, and that some free flakes and strino^s 
of lymph could be scooped out of the cavity. Liver very 
dark, and not syphilitic. 

Autojpsy of mother^ fifteen hours after death^ hy Dr. 



248 OBSTETRIC CLES'IC. 

SoutJiaclt, Curat07\ — Eigor mortis Tvell marked in lower ex- 
tremities, not so in upper. Brain and membranes normal ; 
weiglit 3 xl7. Heart, weight | xi. ; firm white clots in both 
ventricles ; valves and cavities normal. Eight lung, weight 
I XV. ; left 1 xiii. Both were of bright-red color, and on 
section proved to be engorged with blood, notably in then' 
inferior lobes. Liver, weight 3. lbs. 3 5 ; normal. Eight 
kidney 3 vss. ; left 3 ivss. ; normal. 

The whole abdominal cavity, and contained viscera, 
showed flakes of recent lymph, but not enough, or sufficiently 
organized, to agglutinate together the different viscera. Be- 
sides this, there was in the pelvic cavity about one ounce of 
a sero-purulent effusion. The intestinal canal was distended 
by gas, but contained nothing else worthy of note. 

The pelvic brim gave the following measurements : — 
Transverse diameter, 4J- inches ; oblique diameter, 4f inches ; 
anterior posterior, 3J- inches. 

The uterus reached half way up between the umbiKcus 
and symphysis pubis. Weight, 2 lbs. 3 13 ; dimensions, 
5 inches from fundus to os externum. Its greatest transverse 
diameter was 3 inches. The peri-uterine tissue was much 
thickened, and infiltrated with a sero-purulent effusion. The 
uterine cavity was lined by a dirty-grayish exudation, which 
emitted an offensive odor. At parts this could be scraped 
off, showing the peculiar tissue of the uterus of a normal 
color, with shght points of injection. On its anterior wall, 
about an inch from the os externum, in the mesian line, 
there was an ii'regular ulcerated opening, which communi- 
cated with the bladder ju.st behind the bas fond. This open- 
ing was about one-half inch long and one-eighth of an inch 
wide. The distance from it to the bladder was about one- 
quarter of an inch. The opening in the bladder was about 
the same size as that in the uterus. The mucous membrane 
of the bladder was intensely congested, and in an almost 
gangrenous condition around the fistulous opening. The 
neck soft, flabby, and patulous, easily admitting three fingers, 



OBSTETEIC OPEEATIOXS IN DEFORMED PELYES. 249 

showing ill its interior similar clianges to those observed in 
the body. Uterine sinuses empty, with no traces of pns. 
Fallopian tabes presented nothing worthy of note. Corpus 
Intenm of pregnancy in left ovary. 



Case 100. — Transverse presentation / cephalic version ; 
contracted hrim / death of child from premature respira- 
tion ^ perforation and delivery ly Simpson's cranioclast. — 
Dr, Mead, Souse Physician. 

Mary Foy, aged 30 ; Irish ; single ; primipara ; first ex- 
perienced labor-pains May IT, 1867, at 12 p. m., and came to 
the lying-in ward the following morning. 

May ISth, 9 a. m. — Os fully dilated, membranes pro- 
truded, foetal heart audible, pains strong, transverse posi- 
tion of child recognized. It was decided by the house staff 
to perform version by external manipulation, as the mem- 
branes would in all probability rupture before Dr. Elliot 
could arrive, and in effect they ruptured so soon as the at- 
tempt at version was made, when the elbow passed into the 
vagina, and the hand having been drawn down, it was found 
to be to the left. This was at once returned by the house 
physician, two fingers passed into the cervix, and bi-manual 
version effected. The head was brought to the brim, and 
held in position, in the hope that the pains would cause it to 
engage. 2 p. m. — The pains have been regular, but the head 
has not engaged. Dr. Elliot saw the case at his visit at' 3.30 
p. M., and diagnosticated a brow presentation with the left 
hand between the head and the left sacro-iliac synchondi'osis. 
Digital measurement of the conjugate diameter gave a result 
of three inches and an eighth. The hand was retm-ned, 
and during this manipulation, which was very readily and 
promptly effected, a loop of pulseless funis passed into the 
vagina. This left only the safety of the mother to be con- 
sidered ; accordingly, she was etherized, and the head perfo- 
rated through the anterior fontanelle. The right lateral and 



250 OBSTETRIC CLINIC. 

anterior half of the head so pressed against the brim as to for- 
bid the application of a blade of either the cephalotribe or cra- 
nioclast in that position, without previonslj pushing the head 
away above the brim (in which it had not yet entered at all), 
and so rendering the operation more serious, or delaying un- 
necessarily to wash out the brain. Accordingly, the fii-st 
blade of the cranioclast was passed in front of the right sacro- 
iliac synchondrosis, and the second within the skull, when 
the head was delivered promptly, and the body rapidly fol- 
lowed. Third stage of labor accomplished in ten minutes. Or- 
dered ergot and morphia, and oiled silk beneath the bandage. 

May 19^A, 10 a. m. — Pulse 130. Eespiration 24. Patient 
is very despondent, and has been so all the time, partly from 
shame on account of the illegitimacy of the child, and partly 
because its father is a negro. 6 p. m. — Pulse 128. Eespiration 
32. ISTo tenderness over uterus or abdomen. 20^A, 10 a, m. 
— Pulse 120. Respiration 24. Persph-es freely ; discharge 
healthy. ^Ist. — ^Pulse 108. Respiration 30. ^ Tine, verat. 
virid. gtt. iij. quaque tertia. hora. 22^?. — Pulse 114. 23(^. — 
Pulse 80. Continued to improve steadily, and discharged 
well. 

Autojpsy of child. — On opening the thorax the lungs 
were found partially inflated, the pale straw-color of the 
inflated portions contrasting with the mahogany-hue of those 
still remaining in the foetal condition. The straw-color pre- 
dominated upon the borders of the lungs, and was scattered 
in spots over the entire anterior surface. The middle lobe 
of the left lung had the appearance of being divided into 
two nearly equal parts, with a clear line of demarcation 
between the inflated and non-inflated portions. The entire 
lungs floated when placed in water. A portion of the straw- 
colored floated like cork ; a portion of the other sank instantly 
to the bottom of the tumbler. The straw-colored portion 
crepitated upon pressure. A small quantity of yellowish, 
viscid, tenacious fluid was removed from the trachea and 
bronchi, and examined under the microscope, by Dr. W. T. 



OBSTETEIC OPEKATTONS IN DEFORMED PELVES. 251 

Liisk, and was foimcl by liim to consist of amorplious and 
fatty matter, patclies of coloring matter, and flattened epithe- 
lial cells, or, in other words, of the constitnents of the vernix 
caseosa contained in the amniotic fluid. The contents of the 
stomach were of a similar character, with the addition of 
stomach epithelium, and a considerable quantity of blood- 
globnles. The lateness of the hour and the dim light pre- 
vented Dr. Lnsk from tracing the presence of the fluid into 
the remote ramifications of the bronchi. 

Case 101. — Rachitis ; contracted outlet j delivery hy for- 
ceps. — Dr. Nicol\ House Physician, 

Bridget Boyce ; aged 26 ; Irish ; seamstress ; admitted to 
Bellevue January, 1867, in seventh month of her second 
pregnancy. The first child was born three years ago, after a 
natural labor. She is thin, of delicate appearance, with 
marked spinal deformity from posterior curvature. The 
transverse diameter of the outlet is contracted. The labor 
commenced at midnight of March 20th. The os was fully 
dilated, and the membranes ruptured at half-past 6 A. m. on 
the 21st. The pains were strong and frequent during the 
day, but after the head had fully engaged in the pelvis it 
made no further progress. At half-past 8 in the evening 
Dr. I. E. Talyor was sent for ; the patient was anaesthetized 
first by chloroform, and after its effects had been produced 
they were kept up by sulphuric ether. A male child, weigh- 
ing eight and three-quarters pounds, was delivered by Dr. 
ISTicoll, with forceps, in an asphyxiated condition, occiput 
posteriorly, but after twenty minutes of effort respiration was 
established. First stage of labor, six and one-half hours ; 
second, fifteen hours ; third, five minutes. 

Two weeks after the delivery Dr. Elliot examined the 
pelvis carefully, and dictated the following memoranda : 

" The cicatrization, and shortness of the vagina, and the 
size of the uterus, do not allow the fornix of the vagina to 
be so pushed up as to enable the promontory to be touched. 



252 OBSTETRIC CLINIC. 

But inspection of the back and deep abdominal pressure with 
the other hand give me the impression that the promontory 
is drawn backward by the posterior spinal curvature so as to 
enlarge the conjugate diameter. It certainly is not contracted. 
By conjoined manipulation the linea-ilio-pectinea can be 
traced so as to show that there can be no great interference 
with the transverse diameter of the brim. If there be any, 
it is in the slight approximation of the left half of the brim 
toward the median line. On passing down the sides of the 
ossa innominata it is evident that a contraction of the cavity 
in the transverse diameter is produced by the approximation 
of these bones opposite to the acetabula, this being better 
marked on the left side. The transverse diameter is further 
influenced by the projection inward of the spine of each 
ischium ; the right spine is more tilted upward than the left. 
The pubic arch is nearly normal. The transverse diameter 
of the outlet is diminished by the convergence toward each 
other of the tuberosities and ascending ranis of the ischia. 
So far as the curve of the sacrum can be reached it is normal. 
The pelvimeter (Lumley Earle's and King's) indicates that 
between the tuberosities of the ischia there are two inches 
and five-eighths ; and between the spines of the ischia, a 
fraction more than two and five-eighths of an inch." 
The mother and child did well. 

Increasing frequency of pelvic deformity in this coim- 
try. — Dewees states that he only met three cases of pelvic de- 
formity during his long and brilliant career, and there are 
many excellent practitioners in our country, in large practice, 
with a similar experience. Indeed, it is true that the Ameri- 
can women are exempt, as a rule, from these deformities. 
Still the tide of immigration bears with it the same varieties 
of pelves which are described in the works of German, 
French, and other authors ; while the increasing size of our 
cities and manufacturing towns, and the difficulties of obtain- 
ing a bare subsistence without continuous labor in unhealthy 



OBSTETEIC OPEEATIONS IN" DEFOKMED PELVES. 253 

localities, are producing tlie same results here wliicli liaye 
been so Ions; and so well known elsewhere. 

Hence it is not a matter for great surprise that there 
should have been four cases of well-marked pelvic deformity 
in the hospital dm^ing a service of two months ; especially 
when the well-known law is remembered, that difl&eult cases 
of a comparatively rare character display tendencies to group 
themselves, or succeed each other, in hospital practice. 

Practical deduction. — It follows, therefore, that however 
the American obstetrician may heretofore have been justified 
in the anticipation that he might escape these difficulties in 
his practice, those of the rising generation may expect them 
in a steadily increasing ratio. 

The same degree of deformity admits of varying results 
in successive pregnancies. — ITo man can follow the histories 
of successive labors in cases of such pelvic deformity as may 
be compatible with the delivery of a living child — ^if small, 
or favorably moulded so as to fit the diameters — without 
appreciating first, that he may fail to recognize this condition 
in a particular labor which has not demanded assistance ; and 
then, that he must be careful of his prognosis for the future, 
since the next labor may throw a doubt over his well-grounded 
anticipations, and expose him to misapprehension. Moder- 
ate and even serious degrees of deformity present great 
differences in the results of labor allowed to come on spon- 
taneously. Without claiming that labor may be delayed 
beyond the customary period of gestation, it is unquestion- 
able that in very many cases it occurs a few weeks before, 
without attracting much notice, even from the patient. In 
very many cases the period of fecundation is not known, or 
may be assigned to a wrong date. Such conditions modify 
a labor. The difference in the size of a child in different 
pregnancies is not only felt in the range from four pounds 
to twelve, and in the probability of increased size in ratio to 
the number of pregnancy, but a material influence is exerted 



254 OBSTETKIC CLINIC. 

bj the different size of the head of two children weighing 
alike, as well as in fortunate adaptations to special require^ 
ments. Thorough flexion in one case as compared with 
imperfect flexion in another; accurate dip of the head in 
one case instead of an oblique direction; fortunate corre- 
spondence of the head to that diameter which maj be roomier 
than the other ; varying expulsive forces ; differences in the 
ossification and capabilities for moulding of the head, with 
many other influences, affect the results of different labors. 
Some of these we can control in a given case, and some we 
cannot ; while most may be resolved by inducing the labor. 

Case 102, — History of suocesswe pregnancies in a patient 
with contracted conjugate. 

In the first labor I delivered a living child with forceps, 
with the left parietal bone so deeply indented by the j^roni- 
ontory as to allow more than one finger to be laid therein. 
Dr. C. E. Isaacs gave chloroform — child now living ; no 
trace of the depression, with its nervous system and intelli- 
gence unimpau^ed. The second child presented the breech, 
and I arrived when the body was born and the child dead. 
Chin in front, to the right. Dr. Gouley gave chloroform, 
and I rotated the chin posteriorly with forceps and dehvered. 
The third child was smaller, and withholding chloro- 
form — for which she begged piteously — I succeeded, with 
ergot, in driving a living child through the contracted brim.' 
Fourth confinement — January, 1859. ^o memorandum of 
the exact number of hours in labor, nor of the time when the 
waters escaped. By 3 a. m., however, the pains were strong 
and regulai', and the os uteri fully dilated. 7 a. m. — 'Eo ad- 
vance except of the caput succedaneum — head retained by 
the brim. Ergot given until it produced its characteristic 
pains. 8 a. m. — l^o progress. Tagina, which had been cool 
and moist at 5 a. m., now becoming hot and dry. I was 
then called and recommended forceps, which the physician 
in attendance, Dr. Lambert, applied after chloroform had 



OBSTETEIC OPEEATIONS IN DEFOEMED PELVES. 255 

been given, and made powerful traction until they slipped. 
As he was suffering from a severe sick lieadache, which, was 
greatly increased by his efforts at traction, he requested me 
to deliver, and I reapplied the forceps exactly as he had ap- 
pHed them before, and with great difficulty drew the head 
through the brim, rotated the occiput in front and delivered 
a living child, with a laceration upon the cheek midway be- 
tween the eye and the mouth, about an inch long, produced 
by the point of the corresponding blade. This was brought 
together with silver wire at once, but the child died on the 
tenth day from erysipelas, which unfortunately attacked the 
face, and was aggravated by neglect of the parents to feed 
the child properly, the mother having no milk at all. She 
made a good recovery. My forceps were used. 

She was confined for ih.Q fifth time, September 28, 1861. 
After fruitless pains for nearly two days, her labor fairly 
commenced at 9 p. m. The os was then small and dilatable, 
membranes unruptured, right foot easily distinguishable. 
Foetal heart best heard just above the umbilicus. As the 
pains had not done much for her, and she complained of fa- 
tigue, I gave her forty di'ops of McMunn's elixir of opium, 
and left. Scarcely had I done so, before a violent pain came 
on, with rupture of membranes. In abou.t an hour I re- 
tmmed, and found a foot just within the vulva. Thinking 
that the opium might slow the pains, I gave a teaspoonful 
of the saturated tincture of ergot, but the pains did not 
slacken, and were strong and frequent. Every thing advanced 
well, both legs and the breech were expelled naturally and 
without traction. Drew down a loop of cord, which pulsa- 
ted in a satisfactory manner. Hoping now that, notwith- 
standing the deformity with which the previous labors had 
made me so familiar, the labor might be terminated with 
safety to the child, I placed the patient in the customary at- 
titude for obstetric operations, w^ith each leg confided to an 
assistant, and with my forceps at hand awaited the result. 
The left was the posterior arm, and when it came readily 



256 OBSTETEIC CLDsIC. 

within reacli, I simply finished disengaging it, no traction 
being necessary. Dming this time I kept two fingers of my 
right hand within the vagina, slightly pressing back the pe- 
rineum, so that I might gnard the cord from pressure below, 
and feel its pulsations, which continued good. "Waiting thus 
for a pain, I found that the right arm did not advance, and 
had to be disengaged from its position, as it was wedged be- 
tween the head and the right linea ilio-pectinea. After doing 
this, as the pulsations of the cord were satisfactory and no 
struggle of the body for breath had occurred, I waited for an- 
other pain, and then readily delivered the head without in- 
struments, and with no more than the customary scoop. Con- 
fiding the uterus to an assistant, and finding an excellent 
funic pulsation, I divided the cord, but to my sui'prise not 
the slightest efi'ort at respiration took place. Hot and cold 
baths, slapping, sprinkling, insufilation, assiduous use of 
Marshall Hall's method, and the allowing of a half-teaspoon- 
ful of blood to fiow from the cord, had no effect whatever, 
and not even a faint effort at respiration ever rewarded my 
labors, which were unremittingly kept up for forty minutes. 
All this time the heart continued to beat, though with grad- 
ually diminished force, and the ]Dulsations persisted for a few 
minutes after my efforts were relinquished. The child 
weighed more than ten pounds, was well formed, free from 
evidences of injury, with a head quite small in proportion to 
its body. 

The placenta came away readily, and the uterus con- 
tracted well. The mother was attacked with varioloid a few 
days afterward, and seen in consultation with Dr. CatHn. 
She did well. 

I could not explain the cause of the child's death, and 
deeply regretted the refusal of the parents to allow an au- 
topsy. 

External appearances not necessarily suggestive of pelvic 
deformities. — Of the fom' women with peUic deformity 



OBSTETEIC OPEEATIOXS IN DEFOEMED PELVES. 257 

whose cases have just been narrated, tliree were primiparse; 
and presented no external sign whatever which might lead 
one to snspect that the conjugate diameter was lessened; 
while the fom^th had passed successfully through one natural 
labor before entering the hospital. 

This woman, Bridget Bojce (Case 96), attracted attention 
by her deformed thorax, her attitude and walk ; but I have 
often presented cases with such outward deformity to the class 
after perfectly natural labors ; and have often shown not only 
that the pelvic diameters have not been diminished, but that 
some may even be enlarged; while the shallowness of the 
rachitic pelvis may have specially favored a rapid labor. 

These facts enforce the clinical suggestion that we cannot 
judge of the pelvic diameters from the outward appearance 
of the woman, and that we can only rely on careful vaginal 
measurements by the hand or with instruments. 

Still the infrequency of these deformities ; the proper re- 
luctance of women to submit to such explorations ; and the nat- 
ural reluctance of the physician to suggest thoughts of danger, 
when cheerfulness and hope are so desirable, will forever 
multiply such cases as these here recorded, where the first 
suspicion of deformity is awakened by delay in the labor. 

Delayed labor demands pelvic measurements, if these have 
not been previously made. — ^Even then, but too frequently, 
the contingency of deformity of the pelvis is not apt to be 
considered as soon as it ought. "Whenever a labor is de- 
layed, never mind what may be the apparent cause, the pel- 
vis should be inspected, carefully examined, and measured. 

Can these measurements he accurately made? — It is my 
conviction that these measurements can be accurately esti- 
mated in the great majority of cases, and that we should all 
strive to make these results the rule rather than the excep- 
tion. The exceptions must, however, exist, and there are 
clinical reasons why we may not reach our own standard in 
17 



258 OBSTETEIC CLINIC. 

special cases. In these measurements, as in the recognition 
of other physical signs, that man will have the greatest suc- 
cess who is most conscientious, skilled, and faithful in his 
examination, and who patiently examines all the diameters, 
and uses all methods to preclude sources of error. Those 
who know how hard it often is to determine relative shorten- 
ing in a fractured thigh during the progress of treatment, 
will be prepared to appreciate the difficulties involved in 
the accurate measurement of the distance between certain 
points situated deeply within the body, which can never be 
seen except at an autopsy, and which are liable to such pro- 
tean changes. Hence the liability to error is so great, that 
the best men must expect to fail occasionally ; but is this not 
true of all other diagnoses based on physical exploration? 
A man can only do his best, and in the event of error he will 
experience here, as in similar situations, the most lenient 
judgment from those who know most about the subject. 
The practical conclusion to be drawn from the liability to 
error is, that if the consultation should not feel warranted in 
relying firmly on the result of their examination, they should 
give the mother and the child the benefit of any doubt. 

In looking over my memoranda, amounting to about twen- 
ty-seven cases of pelvic deformity in the parturient woman, I 
find much vagueness in the accurate recognition of the char- 
acter and extent of the deformity in many, and may have 
been mistaken in a certain proportion, although nearly all 
have been seen by others. But I have also the satisfaction 
of noting that, with time and . labor, and the aid of pelvim- 
eters, som'ces of error have been more and more excluded ; 
while one case furnishes me with the evidence, drawn from 
the autopsy, that my ante-mortem and the post-mortem 
measurement of the conjugata vera only differed one-eighth 
of an inch; and this deformity was recognized in the hospi- 
tal, after the woman was in labor, with Lumley Earle's pelvim- 
eter; and in the case of Eliza Ford Q^o. 99), the character and 
extent of the deformity corresponded with my diagnosis. 



OBSTETEIC OPEEATIONS IN DEFORMED PELVES. 259 

Case 103. — Deformity of pelvis ; albuminuria j forceps 
and version failing, delivery effected ly craniotomy • use of 
Sinvpson^s cranioclast, as modified hy Barnes; accurate 
measurement of pelvis hy Dr. J. Lumley EarW s felvimeter ; 
pneumonia and metritis. — Bellevue — Dr. WycTcoff, House 
Physician. 

Margaret Dolan, second confinement ; entered the lying- 
in Tvard of Bellevne Hospital on the 9tli of June, 1864, at 
3 A. M. Slie stated to Dr. Wjckoff that on the 9th of Sep- 
tember, 1861, she had been delivered of a living male child, 
which, she said, weighed seven and a half ponnds, and which 
lived to be eleven months and two weeks old. The labor 
was very tedious ; two physicians had been with her, one of 
whom remained with her for twenty-four hours. She re- 
members nothing that the doctors said, cannot say whether 
she took an anaesthetic, but knows that she was unconscious 
during her delivery. Does not know whether instruments 
were used or not. She had a good recovery, sat up on the 
third day, and "went round" in a week. Patient states 
that the waters began to come away on "Wednesday, two 
days before, and that from that time she had been suffering 
from labor-pains of a " short, stinging character." 

First stage of labor completed by 9 A. m. Moderate 
caput succedaneum. Catheterization necessary, and ren- 
dered difficult by pressure of the foetal head. Patient mani- 
fests great irritability. She places herself in every possible 
position on the floor and bed. Frequent cries for assistance. 
Tenesmus constant and annoying, although the bowels were 
recently evacuated. Thirty drops of laudanum without effect. 
Occasional doses of stimulants. Loses self-control. Allows 
examination with great repugnance. Catches physicians by 
the hair. Examination of the urine drawn by the catheter 
reveals a slight albuminous deposit. ; ' 

After waiting thirteen and a half hours from the period 
of the completion of the second stage, there having been no 



260 OBSTETEIC CLINIC. 

advance of the head during that time, and no change in the 
restlessness and mental condition of the patient, Dr. Elliot 
decided that it was hopeless to expect more from the powers 
of natm-e, and that she mnst be delivered instrumentallj. 

There were present, besides the members of the house- 
staff. Dr. Storer, of Boston, and Dr. Swift. 

The foetal heart was beating. Bj the use of Dr. J. Lum- 
lej Earle's pelvimeter (described in the " Transactions of the 
London Obstetrical Society," vol. iii., p. 145), the antero- 
posterior diameter of the brain was made out to be 3f inches. 
The post-mortem measurement made it out to be 3f inches. 
Had the instrument used been properly made by Mr. 
Mathews, of Portugal Street, London, as the inventor de- 
signed, and as delineated in the " Transactions," even this 
trifling discrepancy of one-eighth of an inch would not have 
occurred, but the instrument which I ordered JQ-om London 
only registers quarter inches instead of eighths of inches, as 
engraved in the drawings of the original instrument. The 
case was one in which manual measurement could not be 
accm^ately employed before delivery, because the caput suc- 
cedaneum and a small arc of the foetal head dipped within 
the brim, so as to prevent measurement with the fore-finger, 
and there remained only such guess-work as might be effected 
by the introduction of the fore and middle fingers, and thus 
spanning the portion of the head pressing below the plane 
of the brim. I admit the possible accuracy that can be thus 
attained, if one has graduated blocks to slip between those 
fingers to the metacarpus before their withdrawal ; but the 
instrument of Mr. Earle satisfied me very well indeed in this 
instance. It is a difficult matter to make these measure- 
ments accurately under such circumstances, as every one 
knows who has tried it, and I made several trials before I 
was perfectly satisfied to rely on the results. It surprised me 
to find that it succeeded more to my satisfaction when intro- 
duced in an opposite direction to that for which it was de- 
signed, viz., with the concavity of its curve regarding the 



OBSTETEIC OPEEATIOis^S m DEFOEMED PELVES. 261 

concavity of tlie sacrum, the woman being on lier left side 
Tfith the knees drawn up. 

This measm-ement having been made, and the woman 
being under the influence of chloroform, she was replaced on 
her back, and the bladder emptied with the catheter. The 
first blade of the forceps was then carried behind the left 
acetabulum by a spiral curve (it having been introduced in 
front of the left sacro-iliac synchondrosis), and the other 
was placed in front of the right sac.-il. syn. (the occiput 
being to the right), and were then locked just within the 
vulva. All warrantable efforts at traction were then made 
without avail. The foetal heart was beating to the right, 
and the hand could recognize the funis on the right of the 
promontory just above the brim, in a position which rendered 
prolapse very imminent. The alternatives of version and 
craniotomy remained, and were decided in favor of version, 
although that operation was rendered extremely difficult by 
the long escape of the waters. Efforts at version by external 
manipulation were fruitlessly made, and I then seized the left 
knee and brought the left foot to the vulva, but could not turn 
the child ; the head could not be pushed up from within nor 
from without, nor by conjoined manipulation. It was not at 
all wedged in the brim, but could not be moved far above 
the brim. The funis had, meanwhile prolapsed, and its 
pulsations at last ceased. I then had the head steadied above 
the brim by an aid, and introduced Blot's perforator. To 
bring away the head was a tiresome and long-continued task, 
nor did it pass until most of the parietal bones had been 
brought away piecemeal, and the frontal and occipital bones 
completely crushed by Simpson's cranioclast; only the bi- 
mastoid diameter being left unbroken. Meigs's forceps were 
found useful in removing broken pieces of the parietal bones. 
Churchill's crotchet broke up the brain, and delivery was 
finally effected by the cranioclast. Generally speaking, I 
can deliver with Churchill's crotchet, but not in this instance, 
and expecting great difficulty, I was provided with Scanzoni's 



262 oBSTETEic CLnac. 

cephalotribe. But it was not needed, and the cranioclast 
worked admirably. The operation was fatiguing, and when 
finished there was not a trace of brain left in the remains of 
the cranium. Contraction immediately followed. A large 
and healthy placenta came away in thirty minutes. 'No 
hemorrhage. Child weighed, in its mutilated condition, six 
and a half pounds. The whole time occupied in the delivery 
was two hours and a half. Ergot, opium, and stimulants 
were given. The patient came promptly and satisfactorily 
from under the chloroform. 

June 10th. — ^Patient declares herself well. Pulse 80-90 
during the day. Says that she is a little sore. Urine drawn. 
Has slept easily. During the day she managed to get out of 
ted^ while the nurse was in the next ward^ and walked on her 
hare feet to the water-closet., before she was seen. June Wth. — 
Found leaning over her bed to arrange some things beneath. 
Says that she slept well, but complains of pain in the left 
side. Pulse 100. The evening before, | xxvj of urine were 
drawn. Small amount during the night. Uterine discharge 
slight. Ordered tincture of aconite and hypodermic injec- 
tions of morphia. June 12^A. — Signs of pneumonia over 
base of left lung. Pulse 124-130. Decubitus on right side. 
Face flushed. Short, painful cough, no expectoration. Ab- 
dominal tenderness when deep pressure is made. Lochia 
slight, offensive, and leave a yellowish stain. ]^o swelling 
of external genitals. Bowels moved. Urine slightly albu- 
minous. Oiled muslin jacket to chest. Aconite and the hy- 
podermic injection of morphia. Diet nutritious. Stimulants. 

June 13^A, 12.30 p. m. — Died. Pulse was full and strong 
at 11 p. M. For eight hours before death her respiration 
had been labored. Short, sighing inspiration and long ex- 
piration, with some mucous rattle in the throat. Pupils nor- 
mal. Pespiration never below 16 to the minute. Under the 
aconite the pulse fell, June 12th, at 8 p. m., from 124 to 108, 
and ranged afterward from 104 to 110, rising once to 112. 

Autopsy. — Jtme 14, 1864. — By Dr. Brownell, in the pres- 



OBSTETEIC 0PEEATI0X3 IN DEFOEMED PELVES. 263 

ence of the house-staff, and Dr. Elliot. Weather warm. 
Body very fat. Great discoloration of skin everywhere. 
Face greatly congested. Abdomen greatly distended with 
gas. Peritoneal surface perfectly smooth, with no signs of 
inflammation. About an ounce of clear fluid, however, in 
the cavity. Upper part of vagina much congested. 'No pus 
seen in uterine sinuses, and very little blood. A very small 
quantity of pus in right Fallopian tube ; more in the left. 
Lower lobe of left lung solidified by pneumonia, except along 
the lower edge ; weight, 1 lb. 4 oz. Right lung healthy ; weight, 
1 lb. IJ oz. Spleen large, healthy-looking ; weighed lib. S-J oz. 

Pelvis, — Anterior posterior diameter of brim, three inches 
and five-eighths. Transverse of brim, four and a half inches. 
Outlet undiminished. 

Uterus. — Microscopic examination by Dr. Birkhead. 
Pus in uterine sinuses. ^None under the peritoneum of the 
broad ligament. Heart. — Slight fatty degeneration of the 
muscular fibres. 

Liver and Kidneys. — Prof. A. Flint, Jr., reported that 
" scrapings from the cut surface of the liver presented, under 
the microscope, a field filled with fatty granules and globules, 
with the liver-cells filled with fat." , Dr. Flint also says : " I 
send you a sketch of the appearances in one of the kidneys. 
The convoluted tubes are filled with granules, which have 
not, however, the bright appearance characteristic of fat. 
The appearances in both kidneys are the same. In the 
field are also seen granules, and the renal cells filled with 
granules." 

Pelvimetry. — ^Kot only has Lumley Earle's instrument 
given me satisfaction in this and in other cases, but Yan Hue- 
vel's instrument, which is inore widely known, is capable of 
equal accuracy. I have had much satisfaction in its use in 
measuring the conjugate diameter of the brim, and it is the 
only one I have ever used which is capable of measuring all 
the diameters of the pelvis. When the true conjugate is not 



264: OBSTETRIC CLINIC. 

obstructed, the instrument devised by my friend Dr. Samuel 
"W". Francis has given me satisfaction. Lumlej Earle's pel- 
vimeter has not seemed to me of value in the transvei^e and 
oblique diameters. In the former, the instrument devised by 
Dr. King is the best with which I am famihar ; but I do not 
think that I shall try it any more in measuring the conju- 
gate, as I am satisfied that it is badly adapted to that meas- 
urement, and inferior to other pelvimeters. In the use of 
Yan Huevel's instrument, as in Earle's, a skilful assistant is 
also very desirable. 

Still the difficulties are so great, that we find Churchill 
indorsing with his approval a quotation from Yelpeau in refer- 
ence to the uncertainty of pelvimetry. When we pass from 
the text-books to the records of clinical cases, and the discus- 
sions of medical societies, we find, as might be anticipated, 
a larger latitude given to the liabilities to error. 

Our clinical records show that the autopsy has proclaimed 
the error of one excellent man — as in the case of Yilleneuve 
— who relied on external measurements, and who made the 
customary approximative deductions for the thickness of the 
soft parts of the bones, but was deceived by the unusual 
thickness of the sacrum. Most practical men, however, will 
be willing to appreciate the increased risk of this method of 
examination ; but we find that the autopsy will also disclose 
the error of another first-class man — as in the case of Leh- 
mann, reported by Eodenberg — who rehed on internal meas- 
urement by the finger alone, and who was deceived by the 
unexpected difference between the diameters of the conju- 
gata vera and the conjugata inclinata. 

For this latter, and similar sources of error, the majority 
of men would be less prepared with excuses ; for, perhaps, 
by common consent, the finger of an educated obstetrician 
like Lehmann is considered to be the best pelvimeter. In- 
deed, but very few of the many ingenious instruments devised 
for this purpose, and so well illustrated by Lenoir, have been 
recommended by others than their inventors. 



OBSTETRIC OPERATIONS IX DEFORMED PELVES. 265 

It is true that no measurement can be relied on that is 
not appreciated hj the educated finger; but I deny that 
accurate measurements can be made by the hand alone of 
some of the pelvic diameters, and I claim that the skilled 
use of the instruments will confirm and enhance the accu- 
racy of the measurement of others made by a competent 
man. They will never, however, supply the places of patient 
bedside education of the hand. In confirmation of these 
views, I point to the shadowy and unsatisfactory rules that 
are given for the measurement of the transverse and oblique 
diameters of the brim by the fingers alone. The measure- 
ment is so unsatisfactory, that those who rely on the method 
take comfort in reflecting that the chances of deformity in 
these diameters are less than in the antero-posterior. 

In the cases of Mary Kennedy and Eliza Ford (J^os. 98 
and 99) the hand was relied on for the measurement, and 
pelvimeters were not used, because I felt sure that at the 
worst the forceps would be sufficient for the delivery, as in- 
deed they were ; while in the case of Mary Foy (No. 100) I 
entertained no doubt whatever of the accuracy of my meas- 
m-ement, unless I were deceived as Rodenberg was. More- 
over, in the case of Mary Kennedy, other controlling reasons 
for not using pelvimeters are stated in the history, and are 
applicable to the case of Eliza Ford. 

Difficulty in estimating the size of the foetal head. — We 
find in text-books, and in monographs, tables which give 
the approximative diameters of the foetal head at various 
periods of its development, and differences of a quarter of an 
inch are spoken of with great positiveness. I guide myself 
by these tables, but with a wide margin of allowance ; and 
greatly aid my diagnosis of the size of the foetus by careful 
abdominal manipulations, and measurement of the head — if 
it present — by conjoined manipulation with the fingers of 
one hand in the vagina, and those of the other pressing upon 
the head above the pelvis. In this way we can form some 



266 OBSTETEIC CLINIC. 

idea of the size of the head in a given case, before labor sets 
in, and of its relations to the maternal pelvis. In the five 
cases in which I have induced premature labor for deformity 
of the pelvis, the head of the viable foetus has always been 
able to pass the contracted diameters without any more diffi 
culty than I expected or was prepared for. 

In the cases of Mary Kennedy and Eliza Ford (Nos. 98 
and 99) this manipulation convinced mcthat the heads could 
pass without recourse to craniotomy, when as yet no symp- 
toms of danger to the child or to the mother had developed 
themselves, and determined me to allow further time for the 
moulding of the head and the influence of the expulsive 
forces. And if version be decided against, and the time for 
prematm-e labor has passed, such, in my opinion, is the 
proper practice in well-watched cases where there is only 
one diameter contracted, and that one measm'es three inches 
and a half. 

I could point to several cases of natural labor under such 
circumstances in my experience. Still, with the best care, 
the size of the foetal head and its adaptability to the pelvis is 
the difficult problem in all cases where the deformity does 
not preclude the passage of the bi-mastoid, or incompressible 
diameter ; and compared with this uncertainty the difficulties 
of pelvimetry fall into the second rank. 

The jperf oration of the uterus and hladder hy ulceration^ 
in the case of Eliza Ford (No. 99). — The display of this 
accident by the autopsy surprised me very much, as it was 
unanticipated, and not foreshadowed by clinical signs. 
Moreover, there had been nothing in the labor to specially 
threaten this risk. The head was never impacted, the blad- 
der never over-distended, and it was recorded in the history 
that the head was freely movable above the brim of the pel- 
vis at the time when the operation was resorted to ; that the 
operation of version was feasible, elective, and considered by 
Dr. Taylor and myself, though we decided upon forceps. ITor 



OBSTETEIO OPEEATIONS m DEFOEMED PEL YES. 267 

was the posterior border of tlie symphysis sharper than usual. 
The case, however, is not ahsokitely unique in my experience, 
as I have the memoranda of a . case, under my observation 
nine years ago, where the posterior wall of the cervix uteri 
was perforated by an ulcer produced by the pressure of a 
sharp promontory in a contracted brim, and the commence- 
ment of a similar lesion could be seen behind the symphysis. 

Case 104. — Deformed pelvis ; forceps ; death from per- 
foration of uterus ty sacral promontory, — Dr. George S. 
Hardaway^ Souse Physician. 

Hannah McGuire; aged 18; Irish; primipara; mar- 
ried (?) ; taken with labor-pains at 7 a. m., January 16, 
1858. At 8 A. M. examined by Dr. Hardaway, who noticed 
that the pains were weak, head presenting, and entirely 
above the ilio-pectineal line; os soft, and had not yet com- 
menced to dilate. Pelvis under-sized, but difficulty there- 
from not anticipated. Labor progressed slowty until 9 p. m., 
when membranes ruptured, and most of the waters escaped. 
Os then larger than a Spanish dollar, and dilatable. An- 
terior fontanelle felt on the right side of the pelvis ; sagittal 
sutm-e passing transversely to the left ; posterior fontanelle 
not recognized. Foetal heart distinct in left iliac fossa. 
Pains continued throughout the night, but were not strong. 
At 11.30 p. M. she was brought under the influence of chlo- 
roform, and after this, though the pains continued, she re- 
mained comfortable until 3.30 a. m., when she began again 
to suffer with the pains. She vomited frequently, and had 
an unnatural stare. 

Contraction of the antero-posterior diameter of the brim 
was thought to be the cause of the delay. 7.30 a. m., Jan- 
uary 17th.— Countenance has changed very much since labor 
set in. It is pinched, expressive of anxiety, and she looks 
much older. Head has made no advance. Yagina moist 
and cool. Pulse about one hundred. 

My visit. — ^At this time I was sent for, and saw the pa- 



268 OBSTETRIC CLIOTC. 

tient before meeting with Dr. Hardaway, or hearing the re- 
port of her condition during the night. I had, however, 
seen her in the ward on the previous day, though without 
having had my attention especially directed to her. I was 
much struck by the change in her countenance just described. 
Her pulse at 9.30 was 120 ; her abdomen a little tender ; 
vagina cool, moist, and the discharge perfectly normal. Os 
uteri, in my judgment, sufficiently dilatable for any mode of 
delivery. Head resting above ilio-pectineal line, and de- 
tained there by diminution of the antero-posterior diameter 
of the brim. Sufficiently movable for version or any opera- 
tion. Foetal heart beating. The impression made on me 
was that delivery was called for imperatively, and I preferred 
the use of forceps. 

Consultation. — In the consultation which followed, a dif- 
ference of opinion arose, contraction of the brim not being 
admitted as the cause of the delay, which was attributed 
mainly to feebleness of the pains. After urging my views 
strongly,! deferred and acquiesced in the exhibition of er- 
got, which was given to the extent of twelve grains, in four 
doses, by which time its specific effect began to appear. 

At 3 p. M., or about four hours after the first dose, the 
woman's condition was not improved. She vomited more 
and looked badly. The temperature of the vagina was little 
altered, the discharge was perfectly natural, the head now 
pressed more firmly in the brim. Immediate delivery was 
considered advisable. 

Operation.^She was brought under the influence of chlo- 
roform by Dr. Andrews, and I proceeded to apply forceps. 
The first blade passed rapidly in front of the left sacro-iliac 
synchondrosis, the other, without difficulty, behind the right 
acetabulum, allowing an interval for a long uterine contrac- 
tion. They did not slip, and I rapidly drew the head 
through the brim, rotated the occiput anteriorly, and deliv- 
ered a living male child, weighing six pounds, without lacer- 
ating the posterior fourchette. 



OBSTETEIC OPEEATIONS m DEFOEMED PELVES. 269 

In separating tlie os nteri for tlie introduction of the first 
blade, I felt a warm stream on my fingers, and, holding them 
up, showed them to be covered with a darkish fluid, no trace 
of which had previously been met with in the vagina. 

The placenta gave no trouble. 

Appearance of child. — The head of the child presented 
a deep indentation opposite the fronto-parietal suture of the 
left side, where it had been pressed against the promontory 
of the sacrum, and that bi-parietal diameter was additionally 
lessened by a slighter depression at the opposite point, con- 
fii'ming the diagnosis of deformity at the brim. 

Subsequent management. — A bandage of oiled silk was 
now applied under the binder : 1 j of whiskey, with gr. ss 
of morphia given, the patient removed to another ward, and 
ordered ^ gr. every hour until she slept ; but she only got 
four doses during the night. She slept some, but not well, 
and vomited frequently. 

January ISth. — "When seen in the morning by Dr. H. she 
was not vomiting, and was given gr. ss of morphia, which 
she showed no disposition to reject. Pulse 134. Eespiration 
entirely thoracic ; great tenderness over the abdomen, with 
tympanitis. Ordered J gr. every hour. 

104 A. M. — I saw her when she was gulping up every 
thing she swallowed. Ordered emp. vesic. 6 x 6 to ab- 
domen ; and that she should be brought under the influence 
of opium. 

To check her vomiting Dr. H. gave her gtt. xv. of hydro- 
cyanic acid in four doses, half an hom' apart, without any in- 
fluence on regurgitation. She was given one grain of mor- 
phia every hour by the rectum, and it was attempted to ves- 
icate the epigastrium by Granville's lotion in order to ap- 
ply morphine endermically ; but the lotion was not good, and 
did not vesicate till 5 p. m., when a grain was applied to the 
blistered surface. At 1 p. m. the pulse was 144. 9 p. m. — 
Pulse 176 ; respiration 34, entirely thoracic ; constantly re- 
gurgitating, even the pellets of ice, which were alone given by 



270 OBSTETEIC CLINIC. 

the moutli. Under the uifluence of the opium, she bore 
strong jjressnre over the abdomen without complaining, 
moved herself in bed without pain ; said that she suffered 
none; pupils contracted; wandering a little in her mind. 
Lochia had ceased. Warm poultice to the vulva. 11 p. m. 
— Regurgitation has ceased, having only brought up one 
mouthful since 9 o'clock. Pulse 160, scarcely possible to 
count it at the wrist. Respiration 36. Moaning. Until 1 
A. M. (19th) she continued to take one grain of morphia per 
rectum every hour with no effect on the respiration, which 
continued about the same until death. The pulse could not 
be counted at the wrist after midnight ; after which time she 
was quiet ; did not vomit any more. Died 3.15 a. m., 19th. 

The child seemed likely to do well, but sank and died 
during the night of the 19th. 

Post-mortem by Dr. Lambert, one of the senior assistant 
physicians, twenty-nine hours after death. 

Body well nourished. Cadaveric rigidity well-marked. 
Greenish-yellow discharge from the nose and mouth. ]^o 
discharge from the vagina. Head not examined. Chest. — 
Lungs healthy ; right slightly adherent laterally and pos- 
teriorly. Heart weighed about nine ounces, tissue firm, valves 
healthy, right auricle and ventricle moderately distended 
with blood, left auricle and ventricle nearly empty. The ab- 
domen contained about two gallons of a turbid-broAvnish 
fluid ; near the symphysis pubis there were also several flakes 
of false membrane. Intestines moderately congested. ]^o 
signs of general peritonitis present. Liver rather soft and 
apparently fatty, as indeed it proved to be under the micro- 
scope. Kidneys examined by the microscope, and found 
healthy. In the left iliac fossa there was an abundant infil- 
tration of lymph. Uterus. — This was removed entire, and 
taken by me to Prof. Alonzo Clark, for examination. It pre- 
sented externally no marked evidences of peritonitis, and was 
firmly contracted. 

In the median line posteriorly, just above the junction of 



OBSTETEIC OPEEATIOIs-S Dq- DEFORMED PELVES. 2Y1 

the body with the cervix, was a perforation about the size and 
shape of the button-hole of a waistcoat. The edges were 
clean. Extending downward from this in the mesian line of 
the posterior wall, internally for about one inch, was a solu- 
tion of continuity, involving about one-third of the thickness 
of the organ. Anteriorly in the mesian line was a loss of 
structure, similar in character, but less extensive. The ute- 
rine sinuses displayed coagulated blood when laid open. 

K^o other injury to structure was observable, and these 
were, it will be noticed, just at the points where pressure 
was experienced from the head on the promontory and 
symphysis. 

Microscopical examination. — Careful examination by Dr. 
Clark decided these solutions of continuity to have resulted 
from pressm-e and not from laceration, and therefore there 
was true perforation (not rupture) from death of tissue. The 
fluid lining the inner uterine wall displayed pus under the 
microscope, and on carefully removing some fluid from the 
uterine sinuses with clean instruments, and from fresh in- 
cisions, perfectly-formed pus-globules were found in great 
numbers. To the naked eye, these sinuses did not appear to 
contain pus. 

Beneath the peritoneal covering of the broad ligaments, 
in places pointed out by Dr. Clark, pus was detected with the 
microscope. On dividing the Fallopian tube, pus could be 
readily squeezed from the cut end. 

Pelvis. — This, with the uterus, was shown to the Patho- 
logical Society, and proved to present the recognized deform- 
ity — the antero-posterior diameter of the brim measuring 
three inches, and the promontory leing noticeably sharp ^ as 
well as turned a little to the right. 

Post-mortem examination of the child. — In removing the 
scalp, a portion (about two inches in diameter), overlaying 
the external angular process of the frontal bone and parts 
adjacent, which had been pressed against the sacrum, was 
found infiltrated with blood. Eather less than one drachm 



2T2 OBSTETEIC CLINIC. 

of blood was effused between the dura mater and the upper 
part of this (tbe left) parietal bone. Dura mater not mark- 
edly congested. Pia matter congested. On removing the 
brain, a large clot of blood, weighing about one and a half 
ounces, was discovered beneath the cerebrum on the left side, 
encroaching on the cerebellum. 

JRemarhs. — I have always thought that the commence- 
ment of this lesion occurred on the morning of the 17th, and 
have regretted that my desire for a more timely operation 
was not carried into effect, though it might not have modi- 
fied the result. 

It is interesting to note in this case also, that there was 
no impaction of the head in the brim. It was so movable as 
to have rendered the operation of version possible and elective. 
The reason why the use of ergot was urged, was mainly on 
account of the conviction that the head could mould itself ; 
and pass through the pelvis, and the history of the case de- 
tails the facility with which I drew the head through the 
brim without grooving it, when the operation was decided 
on, notwithstanding that this was proven only to measure 
three inches in the conjugate; a fact which justified the 
hope that the head was small enough possibly to pass unaided. 
The possibility of delivering with forceps through such a 
diameter has been denied, but facts are stronger than the- 
ories. 

In my own experience there has occmTed but one other 
case in which the bladder has sustained serious lesion. 
This was very slight, and cured by an operation. Like the 
others, it occurred in a site where the forceps had never been. 

Case 105. — Cont/racted pelvic 'brim; arrest ; forcejps; 
vesico-vaginal fistula. 

March 28, 1858.— Mrs. Barnett; aged 32; fell in labor 
with her second child; under the care of Dr. O'Korke. 
6 A. M. — He found the membranes ruptured, and that she 
had been in labor ten hours. Os fully dilatable. Presenta- 



OBSTETRIC OPEKATIONS m DEFORMED PELVES. 273 

tion cranial, and above tlie brim. Foetal heart beating. 
Mother's condition good. Twelve hours after this, at Dr. 
O'Eorke's request, I saw the patient with him. Dr. Kiernan 
was also present. Mother's condition good. Abdomen a 
little tender on pressure. Foetal heart and uterine souffle 
distinctly heard at the same site, viz., just below the umbili- 
cus on the left side. Pains growing weaker. Outlet well 
formed. Antero-posterior diameter of brim seemed a little 
over three inches. Head not engaged in brim. Sagittal 
suture transverse. Font an elles not clearly to be distinguished . 
Pelvis shallow. It was decided to apply forceps, because of 
pelvic contraction, non-advance, and suspicious fact that the 
&st child was still-born. Chloroform by Dr. O'Rorke. Forceps 
applied over the oblique diameter, extending from left orbit. 
Having exerted all my strength to no purpose. Dr. O'Rorke 
relieved me, and advanced the head ; as rotation commenced, 
the forceps slipped somewhat, when, having reapplied them, 
I resumed my tractions with all my force, and withdrew the 
head. The child gasped when born, but could not be revived. 
Perineum lacerated. Placenta came away well. Marcli 
^^th. — Pulse 120. Pain over uterus. Blister 6x8 and mer- 
curial ointment, with opium internally. The traction made 
by the forceps in this case was very great, and Dr. O'Rorke 
expressed his surprise that the instrument could bear it. She 
recovered well, but complained of water dribbling from her 
if she stands, or lies on either side. When she lies quietly 
on her back there is no flow, and she can retain her water all 
night. I made an examination, which, however, was not 
very thorough, as I desired to send her to Bellevue, where 
she could have better opportunities for treatment. My col- 
league. Dr. Taylor, made two thorough explorations, and 
discovered, on the last occasion, a small opening to the left 
of the vesical termination of the urethra, in which a small 
probe can pass. The fistula was operated on by Dr. J. J. 
Crane, and completely cured. 

Per contra^ I have delivered in many cases where perma- 
18 



274 OBSTETRIC CLINIC. 

nent and constant pressure must have been made for a long 
time, and no evil result whatever has followed : 

Case 106. — Arrest of head hy jpromontory of sacrum , 
forcejps. 

Mary Com^oy ; aged 26 ; first pregnancy ; in labor from 
October 28th, 5 A. m., 1857, to 29th, 9.30 a. m. Dr. J. R 
Buist, House Physician. In this case the head was retained 
in one place by the promontory of the sacrum for fifteen 
hours, when I delivered a male child weighing ten pounds, 
with Simpson's forceps. Both mother and child did well. 

Case 107. — Forcejps for contracted hrim, 

Catherine White; aged 18; first confinement; Bellevue. 
Dr. James H. Bird, House Physician. In labor from March 
18, 1859, 10 A. M., to March 19th, 12 m. The head was 
grasped between the promontory and pubes in a contracted 
antero-posterior diameter. Delivered with forceps a living 
boy weighing six pounds ten ounces. Chloroform. 

Case 10%.— Forceps in superior strait. 

Ann Mahony ; aged 33 ; first labor ; from May 26, 1857, 
at noon, till May 28th, 6 A. m. Dr. John C. Draper, House 
Physician. In this case the head was arrested in the brim, 
and I finally delivered a female child weighing six pounds, 
with Simpson's forceps. Mother and child recovered per- 
fectly. 

Case 109. — Rigid os and Ungering first stage; douche; 
forceps within the hrim. 

Elizabeth Warren ; aged 25 ; first pregnancy ; in labor 
in Bellevue Hospital, from ISTovember 22, 1857, at 11 p. m., 
to ^N'ovember 25th, 9 a. m. Female child ; eight and a half 
pounds. Dr. C. F. Hasse, House Physician. 

When first seen by Dr. Hasse, the membranes had pre- 



OBSTETRIC OPERATIONS IN" DEFORMED PELVES. 275 

maturely ruptured, os dilated to the size of a two-shilling 
piece, head in first position, pains irregnlar, with scarcely any 
effect on cervix. An emetic and enema were followed by an 
anodyne. 

November 2Uhy 2 a. m. — Os dilated to about the size of a 
fifty-cent piece, rigid and slightly swollen; vagina becoming 
hot ; two warm douches, with very favorable effect. 7 a. m. 
— Almost complete dilatation ; foetal head still obstinately 
engaged just within the brim of the pelvis. Fearing further 
risk to the mother and child from the continued pressure, I 
delivered the latter, living, with Simpson's forceps. The 
mother, who was an hysterical woman, was for some time 
incKned to puerperal mania, bnt finally recovered perfectly. 

November 2Sth. — The child, which was doing well, died 
suddenly, in a convulsion. 

In the following case we decided upon an early delivery 
with forceps, in order to ward off dangers which threatened 
our patient, and to which those with lingering labors may be 
especially exposed, bnt yet without effect : 

Case 110. — Forceps for febrile symptoms in a puerperal 
fever epidemic. 

Ellen Fagan. Eellevue Hospital. Dr. E. B. Barrett, 
House Physician. "Waters discharged March 26th, 74 p. m. 
At 10|- p. M. pains not very efficient, pulse going up, and 
vagina hot. I was sent for. Found the head just emerging 
in the superior strait, first position. Consulted with Dr. B. 
Fordyce Barker, and delivered with forceps at half-past 12. 
Child living ; male ; weighing nine pounds. ISTo laceration 
of perineum. Chloroform. Died on the ninth day, from 
puerperal fever. Forceps decided upon in the hope of dimin- 
ishing the risk from an epidemic of puerperal fever which 
then threatened all our patients. We have seen cases of nat- 
ural labor in which the fatal symptoms have appeared before 
delivery. 



276 OBSTETEIC CLINIC. 

The following case illustrates, among other facts, the risk 
to which the child's eye would have been subjected without 
the pivot, or some corresponding contrivance : 

Case 111. — Forceps for delay. 

Dr. Janes sent for me on the morning of the 29th of 
April, 1860, to a primipara about four feet high, who had 
been in labor about thirty-six hours. The waters had been 
discharged about twenty-four hours before, and no progress 
had been made for the last twelve. The outlet was well 
formed, but the conjugate diameter somewhat undersized. 
The head presented, posterior fontanelle between the sym- 
physis and acetabulum, movement of descent not completed. 
Os uteri thin, rigid, and closely embracing the head ; but 
this, in my opinion, was not the cause of the delay. Con- 
sidering the dm-ation and character of the labor, the patient's 
condition was entirely satisfactory. Foetal heart distinct, in 
the usual place on the left side. She preferred not to take 
any ansesthetic, but when the blades were introduced and 
locked, and the strong tractions necessary to draw the head 
through the brim were commenced, she made so great an 
outcry that we were glad to stop until Dr. Janes had brought 
her under the influence of chloroform, when I delivered a 
living male child of average size, very slightly cut over the 
upper part of the right frontal bone, which was very convex. 
The point of the corresponding blade reached just to the 
eye, which was unharmed. In this case a consultation had 
decided to apply forceps on the evening before, but it was 
not found practicable. Both did well. 

The proper time for operating in delayed and o'bstructed 
lalor. — ^It is easier to lay down rules than to seize the for- 
tunate clinical moment. After a man has seen enough of 
difficult midwifery to have anxiously watched in consulta- 
tion for the fitting moment, to have finally operated, and 
then to have regretted that he had not waited longer ; and, 



OBSTETEIC OPERATIONS IK DEFOEMED PELVES. 277 

on the other hand, when in like <3ircnmstances he has re- 
gretted that he did not operate before ; he at last understands 
the perplexities of the question. 

In the case of Mary Kennedy Q^o. 98), the operation 
might as well, or perhaps better, have been performed a few 
hom'S earlier ; but, upon the whole, it is a satisfaction to re- 
flect that full time was given to nature, and that the opera- 
tion itself was so managed as to give the child the best 
chance in the method decided upon. 

In the case of Eliza Ford (No, 99), the ulceration of the 
uterus and bladder demonstrates that it might have been 
better to have operated before ; but when Dr. Taylor and I 
met in consultation in the morning, there was nothing in the 
woman's condition, or the position of the child, to make us 
anticipate that her chances of a good recovery were less than 
those of Mary Kennedy or Mary Foy. 

In the case of Mary Foy the time for version was well 
selected by the house-staff, but that was a case better adapted, 
perhaps, for pelvic than for cephalic version, on account of the 
pelvic measm*ement, and the original presentation. 

Each case of labor is a problem in itself, and no reflection 
may be more disagreeable than the thought of an operation 
which might possibly have been dispensed with, except the 
regret that one had not been undertaken before. 

I believe, however, that among practitioners competent 
and accustomed to perform obstetric operations, the chief 
tendency to evil results from delay, and trusting to the efibrts 
of natm^e ; an error to which they are inclined by a knowledge 
of the powers of nature, and a familiarity with the difficulties 
and the risks of operative midwifery. 

Practitioners not accustomed to perform obstetric oper- 
ations, but well educated in the theory, are more liable to err 
in the opposite direction from exaggerating the necessities for 
operative interference, and from underrating its risks. Espe- 
cially may this be true of those who have fortunately been 
successful in a limited field, and see no reason to anticipate 



278 OBSTETEIC CLINIC. 

other results. " He jests at scars wlio never felt a 
woTind." 

In competent Lands tlie operation had better always be 
performed too soon tlian a little too late. 

Delivery of the head through the pelvic hrim ly for- 
ceps. — This operation is always difficult, always involves 
risks to the mother and to the child, and demands the great- 
est skill and caution. It may be an operation of necessity 
when the head cannot be pushed back in the uterus, so as to 
admit of version, and the child be living ; it may be an opera- 
tion of election when the head is readily movable, or when 
the child is certainly dead. 

If it lejpossihle that the child is limng. — If the death of 
the child be placed beyond a peradventure, then in cases 
of any special difficulty the child had better be delivered — as 
a law — by the perforator ; but if there be even a hope that 
the child still lives, even though the foetal heart has ceased 
to beat — as a law — dehvery should, undoubtedly, be effected 
with the forceps or by version. 

It is true that the child's life may be placed in great 
danger by this operation, when undertaken from the best 
motives and by the best men, and the risk is in direct ratio 
to the elevation, when other things are equal ; and while this 
additional risk is a motive for deferring this operation in 
many cases, it offers no justification whatever for deferring 
it too long, or for resorting to any deadly operation until 
both forceps, and version, and time, aiid all other methods, 
have been tried, and perhaps tried again. 

It is a painful task to be obliged to struggle for the life 
of the child under circumstances which scarcely leave a hope 
of success, or to be forced to select operations involving more 
risk to the mother, but there is nothing else for us to do than 
to try to save the lives of mother and child, however sad the 
task may be. 



OBSTETEIC OPERATIONS. 279 

Renry YIIL and Najpoleon I. — If it be really true that 
Henry YIII. and E'apoleon I. were asked, by tbe physicians 
in attendance on Jane Seymour and tbe Empress, wbether 
the life of the mother or of the child should be saved ; then, 
indeed, does it seem to me that they asked improper questions 
of those incompetent to judge. The great ISTapoleon's reply 
was the most admirable that could have been made : " Treat 
the empress as you would the wife of a grocer." " Save the 
child," said the horrid King ; " I can get wives enough." 

The only accoucheur who might have been justified by 
history for the destruction of the child born in the purple, 
was ifusa, who was sent for to the mother of ISTero— ^r6> 
jpartu accelerando. 

This ojpeTation sums up all the difficulties with forceps, 
— Delivery by forceps from above the brim may combine all 
the difficulties that can be met with in forceps operations, 
and may be motived by all the causes which determine their 
perfoiTQance when the head is lower down, as well as by 
those which can only exist in the brim itself. The essential 
requisites are, that the cervix uteri should be sufficiently 
dilated or dilatable, and that there should be sufficient room 
for application of the instruments. 

There is a difference of opinion regarding the space de- 
manded, but we have seen that delivery can be effected 
under favorable circumstances when the conjugate measures 
only three inches. Below this diameter success could scarcely 
be hoped for, and the operation is facilitated or rendered im- 
possible by the size of the instruments selected, and the size and 
position of the child's head. The first contingency is under 
the control of the operator, the second may defy his efforts, 
even when the diameters are roomy enough. It may not 
be possible to pass one blade to its place from the fact of. the 
head pressing too closely on the brim in that direction. 

Room for instruments may he obtained by pushing up 
the head, and the head may le steadied against the him. 



280 OBSTETEIC CLINIC. 

Case 112. — Forcej^s ahoroe the hrim. 

A fortunate example of delivery under the most difficult 
circumstances occurred about the year 1856, when it be- 
coming, in the opinion of Dr. I. E. Taylor and myself, de- 
sirable to deliver a woman in Bellevue, in whom the child's 
head floated above the pehdc brim, I proceeded to turn in 
the presence of Dr. Taylor and the house-stafi*. Of those 
present, I remember Drs. John C. Draper and Boiling A. 
Pope. Having introduced my left hand entirely above the 
pelvic brim, I found that the wiist accidentally steadied the 
head by pressure on the chin. Calling for Dr. Simpson's 
forceps, without removing my hand, I delivered a living 
child. Mother did well. 

In the case of Mary Foy (JSTo. 100), the head pressed 
against the anterior and left lateral half of the pelvis, so 
that the cephalotribe could not be applied on that side with- 
out pushing the head so far above the brim as to make the 
operation one of great difficulty and increased risk to the 
mother. A similar case is recorded elsewhere. 

This obstacle to the application of forceps is not confined 
to cases where the head must be delivered through the brim. 
It may occur dm^ing any stage of the passage of the head. 
For cases of this character, where the head cannot be so 
moved as to allow the forceps to pass, Ritgen and Mattei 
have devised special forceps, of which the former admits of 
locking the blades when one has not been able to pass as far 
as it should, and the latter can be locked when the blades 
are not exactly opposite each other, or introduced to an equal 
depth. Both instruments may be serviceable, and even suc- 
cessfid, when other instruments have failed. 

In the following case, if I had made a determined and 
forcible effort to push up the head, the child might possibly 
have been delivered alive. 



OBSTETEIC OPEEATIOi^S IN DEFOEMED PELYES. 281 

Case 113. — Pelmc presentation in an under-sized jpelvis ', 
room singularly obtained for for cejps. 

Jane Holland, aged 21 ; second child. In labor in Belle- 
vue from February 18tli, 2 A. m., to February 19tb, 2.45 A. 
M. Drs. F. A. Burrall and E". Barrows. Child still-born, 
weighed YJ lbs. 

Two years since she was confined with an eight months' 
child, " cross-birth," lived three weeks. ITow at full term. 

February ISth. — ^While preparing for bed, membranes 
ruptured without previous pain. Came immediately into 
lying-in wards, when the left foot was distinguished high up, 
back of foetus to left acetabulum. Dr. Elliot summoned, 
and arrived at 1 A. m., February 19th, just as the knee had 
reached the vulva. 1.40 a. m. — ^Pains being very severe, 
chloroform given moderately, and in a few minutes the body 
of the child passed. After the hips had passed naturally 
into the world, a loop of cord was brought down, which 
could not be felt to pulsate. Motions of the child but an 
instant before had given signs of life, and showed its danger. 

Arms being delivered, and the head refusing to yield to 
traction or the customary manipulations in these cases. Dr. 
Elliot passed the first blade of his forceps promptly to its 
position, but the large head of the child so pressed against 
the right pelvic brim as not to afford any space for the sec- 
ond, and all hope of saving the child soon fled. 

The perforator was sent for, and while making consid- 
erable effort to force a dull instrument through the occipital 
bone. Dr. E. felt the head rise sufficiently on the right side 
to allow the passage of the second blade, when, dropping the 
perforator, he applied his forceps, and delivered with diffi- 
culty. The uterus not being promptly followed down, hem- 
orrhage occurred to an extent which demanded sharp treat- 
ment. Did subsequently perfectly well. Child still-born, 
weighing 7f lbs. 

The head may le made to engage ly external manipula- 



282 OBSTETEIC CLINIC. 

tion. — ^We not -iinfrequeiitly meet with, cases of delayed la- 
bor where the head does not satisfactorily engage in the 
brim, and great assistance may often be given by pressure 
with the hand placed over the mother's abdomen, so as to 
alter the position of the child's head, increase the flexion, or 
force it into the brim. The following cases illustrate this 
manoenvre. 

Case 114. — Forcejps in an under-sized hrim / rigid os ; 
jprevious pressure of the head into the 'brim hy the hand. — 
Dr. Charles H. Ludlum^ House Physician. 

Mary Leonard ; Irish ; aged 33 ; Belle vue. The pains 
came on at Y p. m.. May 24, 1866. Since she became preg- 
nant she has never felt well. Has had more or less cough, 
and gradually grown weaker. The os was found high up 
in the posterior j)art of the pelvis, barely admitting the in- 
dex-finger, and exceedingly hard. The pains continued fre- 
quent and severe, and by 2.30 p. m. the os had begim to di- 
late, admitting the tip of the middle finger by the index. 

At 4.30 p. M. Dr. Elliot saw the patient, and found the 
OS slowly dilating, having then attained the size of a twenty- 
five cent piece. It was still very unyielding, although her 
pains were agonizing in the extreme, causing her to shriek, 
and to try every imaginable position for the sake of relieving 
herself. Dr. E. made out a vertex presentation, the head 
being above the brim and overhanging the pubis. Besides, 
he found the brim of the pelvis somewhat under-sized, the 
sacro-vertebral angle being more prominent than normal. 
As the OS was now dilating somewhat, and the membranes 
unruptured, he concluded to leave the case to ^N'ature for a 
time, promising to call again at 7 p. m. The pains were still 
very violent, and seemed to be wearing out the patient's 
strength. At 6.30 p. m. the os had dilated considerably, but 
the rim, during a pain, felt like cartilage, and the cervix 
was quite oedematous. 



OBSTETEIC OPEEATIONS. 283 

At 7 p. M. Drs. Elliot and Taylor arrived and confirmed 
the diagnosis. As tlie os had now dilated pretty fully, it 
was decided to rapture the membranes and cause the head to 
engage in the superior strait. Dr. Elliot ruptm'ed the mem- 
branes and succeeded by abdominal pressure in forcing the 
head into the pelvic brim. Drs. E. and T., on consultation, 
decided to leave the case to natm-e for a couple of hours, 
when if little progress had been made, forceps should be used. 
On their return at 10 p. m. but little progress had been made ; 
the lips of the os, especially the anterior one, had become 
very oedematous, and the patient's strength was failing. Be- 
fore applying the forceps, Dr. Elliot endeavored to dilate the 
OS by means of Barnes's dilators, but was unsuccessful, as it 
was impossible to insinuate them between the os and the 
head, as the latter was constantly pressed down by the pains, 
which were still as severe as ever. The warm douche (about 
a gallon), followed by manual dilatation, was more successful. 
She was then anaesthetized by Dr. Lewis Fisher, the senior 
assistant, and at half-past ten Dr. Elliot applied the forceps, 
the posterior fontanelle being applied to the left ilium trans- 
versrely. After considerable exertion he succeeded in rota- 
ting the occiput under the pubes, and delivering a living 
boy weighing seven pounds, and feeble. A free employment 
of the ordinary means completely established the respiration. 
There was a caput succedaneum over the right posterior por- 
tion of the scalp, and a slight mark over the right eye corre- 
sponding to the point of application of the forceps. The 
uterus contracted nicely, and the woman did well.. 

Case 115. — Occiput pressed against linea ilio-pectinea, 
rotating from left acetabulum to near the right sacro-iliao 
synchondrosis, and made to engage hy manipulation. 

At 1 A. M., December 12, 1864, I was called to Mrs. 

, in labor with her third child. Os uteri dilated, 

and sufficiently dilatable to allow the passage of the head. 



284 OBSTETEIC CLINIC. 

Membranes unruptiTred and not tense. Post. font, to left 
acetabulum. Foetal heart on left side, not audible on right. 
The cause of delay was the fact that the occiput had struck 
the linea ilio-pectinea. 9 a.m. — Occiput still on the linea 
ilio-pectinea. Foetal heart distinct on right side, not audible 
on the left. Os uteri fully dilated. Membranes passing 
through. 4 p.m. — Foetal heart not audible anywhere, but 
the foetal movements yery distinct. On carefal examination 
I found the occiput still on the linea ilio-pectinea, and now 
directed to a point midway between the centre of the right 
ilium and the right sacro-iliac synchondrosis. Pains had 
been strong all the while. 'No sleep. The head, therefore, 
pivoted on the linea ilio-pectinea, and had made a half tm-n 
of the pelvic brim. I then ruptured the membranes, passed 
my right hand within the vagina, and pulled against the 
upper and posterior parietal bone, while I made pressure on 
the head with the left hand thi'ough the abdominal wall. 
In this way I flexed the head satisfactorily, and made it en- 
gage. The advance was then very rapid, the occiput rotated 
anteriorly, and by 6 p. m. a girl, weighing nine pounds, was 
delivered naturally. 'No caput succedaneum. Between the 
apex of the posterior fontanelle and the occipital protube- 
rance there was a depression, caused undoubtedly by the 
pressure against the linea ilio-pectinea. Both did well. 
Chloroform from 4 p. m. until after delivery of the placenta. 

Case 116. — Ante-partwn hemorrhage j' rotation of head 
hefore engaging in the 'hrim ', forehead jpresentation con- 
verted 'by the hand into that of posterior fontanelle. 

Mrs. was awakened during the night of the 11th of 

December, 1864, by uterine hemorrhage, which was not ex- 
cessive or alarming, and when I saw her at 8 a. m. of the 
12th, there was still a moderate flow with some clots in 
the vagina. The os uteri was dilated to about three inches 
in diameter, and the membranes unruptured ; liquor amnii 



OBSTETEIC OPERATIONS. 285 

evidently in large quantity. Cannot tonch placenta. Post, 
font, to left acetabulum. Foetal heart distinct on tlie left 
side, and heard somewhat on the right. Pains feeble. Dur- 
ing the morning there was a little flow, and the discharge of 
a small clot the size of an orange. The membranes passed 
down, the head remaining at the brim, and at 2 p. m. I rup- 
tm-ed them, when the discharge of waters was excessive. On 
examining the head I found that the posterior fontanelle had 
moved around toward the right sacro-iliac synchondrosis, 
and that the anterior fontanelle was carried down by the 
gush of water, so that the occipito-frontal diameter was in 
the brim, and the os frontis distinct to the touch. Having 
given ether, I then pushed the brow well up ; and again, in 
half an hour, I repeated the manoeuvre, which liad once more 
been rendered necessary by descent of the forehead. After 
this I gave a couple of drachms of a saturated tincture of 
ergot, when flexion was maintained, and the occiput rotated 
anteriorly and came under the symphysis. After the birth 
there came a double handful of clots. Placenta gave no 
difficulty. 'No fm-ther trouble. Both did well. Child — a 
boy weighing nine pounds. 

The head made to engage in the trim hy altering the 
mother^ s position. — ^We may succeed in forcing the head to 
engage in the brim by altering the mother's position, even 
in cases where there is no marked uterine obliquity, and thus 
facilitate the application of forceps, if the labor should not 
then terminate naturally ; as in the following case : 

Case 117. — The movement of descent Ir ought about hy 
changing the ^position of the mother / forceps. 

Pose Hay den ; aged 23 ; first ; Lying-in Asylum. The resi- 
dent physician. Dr. Wilson, sent for me on the 24:th of Febru- 
ary, 1860, to this patient, whose labor had commenced in the 
night of the 21st. During the 22d no progress had been made. 
Pains good. Morphia. On the morning of the 23d the os 



286 OBSTETRIC cLimc. 

was not sufficiently dilated to allow the presentation to be 
made out. By midnight the os was well dilated, and the 
waters discharged. The head then rested on the brim anteri- 
orly, and did not dip within the true pelvis. Having ele- 
vated the hips and depressed the shoulders, the movement of 
descent commenced, but the pains now became irregular and 
the patient feeble. When I saw her at 10 a. m. she had been 
vomiting a clear green fluid. The head was presenting with 
the posterior fontanelle to the right acetabulum. Os fully di- 
latable, but had not yet slipped over the head. The greater 
part of the head was yet in the brim, and the caput succeda- 
neum very large. Foetal heart and uterine souffle most dis- 
tinct over the left umbilical region. Dr. Wilson brought 
her under chloroform, and I introduced the first blade readily 
in front of the left sacro-iliac synchondrosis, but moved it up 
under the left descending pubic ramus with much difficulty 
on account of the size of the head. The second could only 
be introduced after much trouble, and a thicker one could not 
have been passed at all ; and as it was, I could not introduce 
it as far as was desirable, and was obliged to withdraw the 
first a little in order to lock them. The cervix uteri did not 
interfere, and both blades were well within it. I moved the 
pivot to the second hole, but found it necessary to move it to 
the first. The delivery was difficult, and required all my 
force, but the tractions were chiefly made with the trans- 
verse bars, from fear of injuring the foetal head, which I knew 
to be exposed to danger from the position of the blades and 
the necessity for altering the pivot. The child was born liv- 
ing, weighed eight and a half pounds ; left angle of the fron- 
tal bone marked with the forceps ; the point of the corre- 
sponding blade resting over that eye, which was uninjured. 
Skin behind the right ear slightly abraded ; no paralysis of 
portio dura. Perineum not at all lacerated. Placenta came 
away well. Ergot and then morphia. Both mother^ and 
child recovered nicely. 



CHAPTER X. 



CHOICE, USES, Am) APPLICATIONS OF FOECEPS (CONTINUED). 



Introduction of forceps -^ithin the cervix uteri. — Case: Puerperal eclampsia; 
albuminuria; douche; forceps within the cervix. — Case: Eclampsia; 
douche; forceps delivery through a moderately dilated cervix. — Case: 
Eclampsia in the eighth month ; extraordinary family history ; rigid cervix ; 
douche; dilators; forceps. — Case: Forceps for arrest of head in superior 
strait from extension of head ; manual efforts at forceps unavailing ; appli- 
cation of forceps; laceration of cervix. — Case: Rupture of uterus at its 
vaginal attachment; forceps. — Incision of cervix. — Case: Eclampsia; ab- 
solutely unyielding os and cervix ; douche ; incision ; forceps. — Application 
of forceps in the brim. — In contracted conjugate the head transverse, and 
seized obliquely. — Case: Delayed labor; forceps and conversion of a right 
occipito-posterior position ; facial paralysis of child, and its recovery after 
convulsions. — Head seized in one of its oblique diameters. — Choice and uses 
of forceps. — Best use is that of a tractor. — Case : Eorceps. — Case : Forceps ; 
perforator. — Case: Illustrative of great tractive force; forceps; perforator. 
— Case: Powerless labor with rigidity ; ergot and forceps. — Case: Forceps; 
impacted head; perforator. — Case: Forceps and laceration of vagina; sub- 
sequent application. — Case: Forceps; tedious labor from rigidity ; advan- 
tage of touching the head and forceps blades through the rectum during 
delivery, — Case: Forceps for delay; still-bom child; death of child and 
diflficulty in delivery believed to have been due to the encircling of the neck 
by the funis. — Application of the anterior blade. — Position of the patient in 
forceps and operations. — Case: Forceps for delay ; cord tightly around the 
neck. 



Introduction of forceps within the cervix uteri. — The 
blades of the forceps must inevitably be introduced within 
the cervix, to a certain distance, in a large proportion of 
cases ; but it occasionally happens that if they are to be used 
at all, they must be introduced so as to seize the head which 



288 OBSTETEIC CLINIC. 

has not yet commenced to escape tlierefrom, and wliile tlie 
cervix is barely dilated enongli to admit a slender pair. 

SucL. necessities increase tlie difficulties, tlie uncertainties, 
and tlie dangers of tlie delivery. The lining membrane may 
be bruised, the cervix torn badly, and after all the delivery 
be impossible unless the cervix be incised, or measures taken 
to secure its dilat ability. Such results multiply the risks of 
subsequent puerperal inflammations, even though they pro- 
duce no other effect. Still, these dangers must be incurred 
in certain cases, and it must be remembered that the cervix 
uteri is liable to be lacerated in a large proportion of natural 
labors, especially among primiparse. My experience has 
taught me that forceps applied in this way may succeed in 
dilating a rigid cervix which was undilatable in manipula- 
tion. "When, therefore, the condition of the mother, or of the 
child, or of both, demands immediate delivery, a tentative 
application of forceps may be made in their interest, though 
the cervix be not satisfactorily dilated or dilatable, provided 
only that the blades of a slender forceps can pass. 

Case 118. — Puerperal eclampsia j albuminuria; uterine 
douche / forceps within the cervix. 

On the 25th of March, 1862, I was sent for in consulta- 
tion with Drs. M. 0. and Y. B., to see Mrs. M , a multi- 
para, about forty years of age, near her full term, with puer- 
peral eclampsia, associated with albuminuria. She was very 
feeble, unconscious, and without any of that physiognomy 
often found in cases of convulsions dependent upon urgemia. 
She had been many times convulsed without regaining con- 
sciousness in the intervals, nor indeed did it ever return. 
The cervix uteri had been undilatable and the pains ineffect- 
ual. The warm uterine douche had been used by Dr. M. 
with the effect of procuring a certain amount of dilatation 
which would yet, however, scarcely authorize an attempt at 
version. The foetal heart was beating, and the head pre- 



FOECEPS WITHm THE CEEVIX. 289 

senting and felt to be eutii-elj within the cervix. Her con- 
dition demanded prompt measnres of relief, and, in the jndg- 
ment of all the consultation, the choice of operative measures 
lay between forceps and perforation; nor v^as much hope 
felt that forceps conld possibly be applied. "With the per- 
mission of all, I carried my forceps entirely within the par- 
tially dilated cervix, and succeeded in locking them upon 
the foetal head, after which I dilated the cervix by drawing 
the head ^ steadily and firmly upon it with the forceps, and 
delivered a li\dng child. The mother remained unconscious, 
sank steadily, and died within twelve hom^s. The child was 
spoon-fed, and died when a week old. 

Case 119. — Puerperal eclampsia j douche i forceps ; de- 
livery through a ^moderately dilated cervix. 

Dr. Bishop sent for me on the 14:th of April, 1862, in 

the afternoon, to see Mrs. McD , a primipara, aged 19, 

who had been taken with puerperal convulsions in the morn- 
ing, which had continued during the day without any inter- 
val of consciousness. The urine was markedly albuminous, 
and her mother stated that there had been great oedema of 
the feet and legs up to the waist for three or four months 
before her confinement. Her hands also had been so swollen, 
that she had been obliged to remove her wedding-ring. The 
foetal heart was beating, and the cervix was just sufficiently 
dilated to permit the introduction of my forceps upon "the 
head, which had not yet commenced to pass through the 
neck. Such dilatation as there was had been effected by the 
warm douche, which Dr. Bishop had been injecting against 
and within the cervix. Accordingly, both blades were pass- 
ed within the cervix, upon the head presenting in the first 
position, and a living child was delivered, of a normal size. 
The head was of necessity marked ; since, to draw the 
head through, and then dilate the unyielding cervix, it had 
been necessary to bring the blades together as closely as 
19 



290 OBSTETEIC CLDnC. 

was justifiable. The child was revived with some difficulty, 
but then seemed to do well, though it died on the second 
day. 1^0 post-mortem could be obtained. 

The mother had many convulsions after her confinement, 
and did not recover her consciousness for twenty-four hours. 

After this time she remained very anaemic and weak, 
and was obliged to keep her bed for three weeks, and then 
suffered from faintness when she assumed the erect posture. 
There were no symptoms of metritis, peritonitis, or material 
injury from the operation. Gradually, however, she regained 
her strength, became again enceinte, and miscarried in l^o- 
vember, 1862, at the end of the second month. 

At the time of the convulsions the m-ine was examined 
by Dr. "Wm. H. Draper, with the following result : " Sp. gr. 
1021. Reaction acid. Under the microscope numerous 
casts, generally of the smaller tubuli ; some of them are per- 
fectly transparent, others have one or two coarsely granular 
epithelial cells attached, and others again are slightly granu- 
lar, some of the granules having the bright glistening appear- 
ance of oil. The bottle was not perfectly clean, and must 
have contained greasy matter, from the amount of oil found 
in the field of the microscope." 

In this case the convulsions were as severe and continued 
as in the gravest class of cases. An examination of the urine 
many months after showed it to be perfectly healthy ; spe- 
cific gravity of the normal mine, 1016. 

When I last heard from the patient she was approaching 
the term of her third pegnancy. 

Case 120. — PuerjpeTal eclamjpsia in the eighth month ; 
extraordinary family history ; rigid cervix / douche / dila^ 
tors ; forceps. 

Dr. John A. Brady, of "Williamsburgh, sent for me on 
the 8th of October, 1867, to a young primipara, aged 23, 
in the eighth- month of her pregnancy, with eclampsia, 



ur 



FORCEPS WITHIN THE CEEVIX. 291 

and informed me of tlie following remarkable facts in evi- 
dence of a very singular hereditary predisposition to eclamp- 
sia. The mother of the patient had given bu^th to four 
daughters, and had then died from puerperal eclampsia in 
the delivery of a son, who is now living and well. Of the 
foiu- daughters, one died of eclampsia at the sixth month 
of her first pregnancy. Another had two miscarriages at an 
early period of pregnancy, and then died in eclampsia in 
the third, leaving a living child which weighed less than four 
pounds. The third sister had eclampsia at about the sixth 
month of her first pregnancy, and recovered. She has since 
had a miscarriage. 

Under these circumstances Dr. Brady had carefully 
watched the urine of this patient during the pregnancy, 
without finding any albumen until about a fortnight before 
the convulsions, when it appeared in large quantity. Hot- 
air bath and salines caused a diminution, but it would recur, 
and the day before the attack the urine had almost solidified. 
The question of inducing labor v^as under consideration when 
she was seized with labor -pains and well-marked eclampsia, 
at about 9 a. m., October 8th. 

I found her moderately under the influence of chloroform, 
the exhibition of which was shown then and subsequently 
to be absolutely necessary for warding off the recurrence of 
the attacks, which, however, amounted to some ten or twelve, 
of a very violent character, dmdng the day. Her jactitation 
and restlessness were painfully marked. The bowels had 
been very freely moved on previous days, but they were 
again acted on freely by stimulating injections. Some urine 
drawn with the catheter showed a very large quantity of albu- 
men when boiled. The question of the abstraction of blood 
came up with peculiar force in this instance, from the fact 
that venesection had been used in the case of the only sister 
who had recovered. But the pulse was so feeble that when I 
first touched the wrist it demanded care and attention for its 
recognition, and such had been its characteristics for some 



292 OBSTETRIC CLINIC. 

time before the labor. Slie was pale, ansemic, feet and legs 
oedematous, face a little puffy. Still in tbe course of the day 
we ventured on the withdrawal of a conple of ounces of 
blood by cups, from the temples, without injurious effects, 
but we did not consider it safe to take any more. At 1 p. m. 
we introduced the smallest-sized dilator with difficulty within 
the yery rigid cervix. The soft parts were rigid and not 
relaxed at all. By 4 o'clock we had faithfully tried the 
dilators, douche, and manual dilatation, and had ruptured the 
membranes. The head was presenting, but not pressing on 
the long, narrow, and rigid cervix. This was dilated to a 
fraction over two inches by measurement, and as undilatable 
as ever. The patient's condition was so very unfavorable 
that we decided that an effort should be made to introduce 
the forceps within the cervix, and endeavor to procure dila- 
tation by traction on the head. Foetal heart distinct. This 
I managed to accomplish with my own instrument, and 
when introduced it was tightly embraced between the lock 
and fenestrsB by the cervix. When the second blade was 
slipping to its place — a movement in which no force was 
used — a moderate stream of dark blood came from the 
cervix which we believed to depend on detachment of the 
placenta. Tractions were ineffectual, and we did not like to 
divide the long and thick cervix, so we decided that the in- 
strument should be withdrawn, and the trickling of blood 
soon after ceased. Shortly after the tips of the fingers of 
one hand were felt by the side of the head, and pushed up. 
We now repeated the douches, and did oar best with the 
dilators. We distended these with our best efforts, but with 
little effect, though the j)ressm^e of the rigid cervix was such 
as to spring a leak in one dilator, and bm-st the pipe of the 
syringe. . We also gave a cou]3le of drachms of Squibb's 
fluid extract of ergot to increase the pains, and some alcoholic 
extract of belladonna by the mouth, and a stimulating enema. 
Dr. B. and I tried manual dilatation thoroughly. Between 8 
and 9 o'clock we had dilated the neck to a diameter of be- 



FOECEPS WITHEN' THE CEEVIX. 293 

tween two and a lialf and three inches, and the head had 
come down so as to press upon it ; and as the foetal heart was 
beating, the convulsions recuiTing, and the patient's condition 
very unfavorable, it was decided to make another effort with 
forceps. On this occasion no flow of dark blood followed. 
They were introduced and locked, but the delivery demanded 
time with intervals of rest, and strong connter-pressnre, and 
manual dilatation of the cervix, which yielded with great diffi- 
culty. However, a living child was brought into the world, 
the head seized in the bi-parietal diameter, and the sides of 
the face marked by the pressure of the blades. The pivot 
had not been used, as the size of the head did not demand 
it, and consequently the rigid cervix pressed the blades 
powerfully against' the head. during its transit. The placenta 
came away well, and the uterus contracted nicely. Eespira- 
tion remained hurried. No urine was found in the hladder 
afUr 1 p. M. of the %th. Microscopic examination, by Dr. 
Brady, of the m^ine then drawn, showed abundance of waxy 
casts, and epithelial cells, and fat globules. The patient 
recovered a partial consciousness after delivery, and at 1 a. m. 
her pulse was 102 ; respiration 34. She then raised her 
pelvis from the bed, and had some moderate flooding. Pulse 
went up to 168, and she died at 4 a. m. of the 9th. E'o 
autopsy. Child died fifteen hours after delivery. 

In these difficult and responsible applications of forceps 
there is a certain risk that the cervix might tear badly and 
involve the peritoneum — a risk which also attends a natural 
labor. 

Case 121. — Forceps for arrest of head in superior strait 
from extension of head j manual efforts at flexion unavailing / 
a/pplication of forceps ; laceration of cervix. — Bellevue — Dr. 
Elisha Kinney^ House Physician. 

J H ; married ; aged 29 ; first confinement ; in 

labor from May 9th, 5 A. m., to May 10th, 4 p. m. ; still-born 



294 OBSTETEIC CLmiC. 

girl ; eight pounds ; occiput to the left ; first stage, twentj-two 
hours, when membranes ruptured ; partial descent, and then 
arrest, when the head remained stationary for fifteen hours. 
I was then sent for, and found that the chin had departed 
from the breast, and that the anterior and posterior fonta- 
nelles were in the same place. Fate of child as yet doubtful. 
'Not being able to move the head, and the woman's condition 
obviously demanding relief, I applied forceps. There was 
no room for the second blade, except by carrying it directly 
to its place behind the right acetabulum, which was accord- 
ingly done; blades readily locked, and delivery eflPected 
without difficulty. Chloroform. Bladder previously emp- 
tied. The condition of the funis showed that the child must 
have been dead for several hou.rs. The placenta came away 
readily, but the uterus did not contract well, and there was 
a considerable amount of post-partum hemorrhage before 
ergot and ice brought about contraction. Patient came 
sluggishly from under the chloroform. Surface cool, pulse 
weak, and died in fourteen hours. 

Autopsy. — Heart normal. Lungs do. ; old pleuritic adhe- 
sions both sides. Intestines tympanitic. Parietal peritoneum 
intensely injected over uterus. Uterus moderately well con- 
tracted. Sinuses filled with coagula ; no pus discovered in 
them. On the inner surface of the uterus, posteriorly and 
inferiorly, one or two spots puriform in appearance, not 
examined microscopically. Pus in one Fallopian tube. Pos- 
terior wall of cervix on the right side torn obliquely to the 
peritoneal coat — this not involved. Liver under-sized, and 
apparently fatty. Kidneys both fatty. Spleen normal. 

It is interesting to note, from the nature of the applica- 
tion, that neither blade of the forceps went in or near the 
position of the lacerated cervix. 

There was reason in this case for believing that metritis 
had set in during the labor — an occurrence seen occasionally 
in lying-in hospitals. 



KUPTUKE OF TJTEEUS. 295 

Case 122. — Biijptiire of uterus at its 'vaginal attachment ; 
forceps. — Bellevue — Dr. Hiclcs, House Physician. 

Catlierine Logau ; Irisli ; married ; aged 30 ; second preg- 
nancy ; menstruated for tlie last time in January, 1860 ; 
labor commenced October 1, 1860, at 4 p. m. ; presentation 
L. O. A. ; labor terminated October 2d, at 11.15 a. m. ; first 
stage, four bom-s ; second, fifteen bours ; tbird, five minutes ; 
cbild, male ; weigbt, ten pounds ; still-born, putrid. 

I was sent for to tbis patient between 6 and 1 a. m., Octo- 
ber 2d, and arrived at about 9, and found tbe patient col- 
lapsed, witb anxious countenance, constant vomiting, excessive 
tbirst, sm-face cool and damp. All pains bad completely 
ceased. Drs. Taylor and Barker were sent for in consul- 
tation,' but botb being out of town, I proceeded to deliver 
witb forceps, an operation demanding considerable tractive 
efibrt on account of tbe large size of tbe cbild, wbicb from 
appearance seemed to bave been dead several days, as tbe 
skin could be readily detacbed. ITo ansestbetic was used, tbe 
condition of tbe patient sufficiently contra-indicating its em- 
ployment. Hemorrbage did not occur, and tbe uterus con- 
tracted down promptly, and remained firm and bard. Brandy 
and morpbine were now administered freely, wbile a stimulat- 
ing lotion of brandy, salt, and tbe tincture of capsicum, was 
applied to tbe surface. Tbese measures seemed for a wbile 
to produce a favorable result, tbe pulse appearing to increase 
somewbat in volume— tbougb tbe vomiting still continued 
witb unremitting activity and persistence unto tbe end, not- 
witbstanding tbat a large variety of expedients were adopted 
for its relief. ISTo perceptible cbange occurred in tbe condi- 
tion of tbe patient until Thursday, October 4tb, when sbe 
died at 6 A, M. Tbougb frequent attempts were made to 
nourisb tbe patient by tbe moutb, tbey were invariably abor- 
tive, being instantly ejected from tbe stomacb, and after 
tbree or four enemata of beef-tea and brandy, as promptly by 
tbe rectum. 



296 OBSTETEIC CLINIC. 

Aiitojpsy. — Disclosed a ruptiu-e of the vagina at its pos- 
terior cul-de-sac at its junction with the uterus, through 
■which Dr. Ferguson, having introduced his hand in the ab- 
domen, readily pressed two fingers in the cavity of the uterus. 
There was a large effusion of clotted blood in the peritoneal 
cavity which escaped when the cavity was opened, but no 
other evidences of inflammatory action than a slight injection 
of the serous coat could be found. The uterine tissues in the 
vicinity of the rupture were softened and infiltrated with 
blood. Uterus well contracted. The pelvis seemed suffi- 
ciently roomy, but the promontory and the linea ilio-pectinea 
presented a sharp and prominent edge, though without pro- 
jecting spiculse. 

Incision of cervix. — The following case occmTcd about 
nine years ago, and offers as well-marked an illustration of a 
rigid OS and cervix as could be presented : 

Case 123. — Eclampsia i absolutely unyielding as and 
cervix / douche; incision i forceps. 

The following case is in the words of Prof. Samuel 
Percy : 

" Catherine H- ; aged 26; primipara. I was called 

U23on to attend this patient at the solicitation of Dr. James 
Hyslop, as he had a previous engagement in another part of 
the city. The patient had for the previous month or six 
weeks complained to her friends of swelling of the hands 
and arms, and of the whole of the upper part of the body, 
and also a puffiness of the eyelids which made it unpleasant 
to move them ; the urine was scanty, and at times highly 
colored. She asked no advice, as she was assm-ed by her 
friends that it was nothing unusual. She had during the 
afternoon walked to her sister's, a distance of more than two 
miles. Shortly after arriving, she was troubled with labor- 
pains, and through the evening, as they increased in severity, 
slight convulsions accompanied each pain. When I fii'st saw 



I^SrCISION OF CERVIX. 297 

her, at 1 a. m., tlie couviilsioBS were so severe tliat slie did 
not recover lier consciousness afterward. I fonnd tlie os 
sliglitlj dilated, but not more tlian sufficient to pass with 
difficulty two fingers, and quite undilatahle. The bladder 
was distended, and I drew off with the. catheter about twenty 
ounces of dark bloody urine. I put her immediately under 
the influence of chloroform, and kept up its effect until 4 
o'clock p. M., during which time she had but one convulsive 
paroxysm, which occurred while my attention was drawn 
from her for a short time, so that she passed from under the 
influence of the chloroform; but during this whole time, 
with every pain, there was a threatened convulsion, which 
was subdued only by the chloroform. I administered nau- 
seating emetics, and abstracted blood, in the hope of procur- 
ing dilatation ; but, at the expiration of twelve hours, the os 
was as undilatahle as at first. I could not at any time hear 
the foetal heart, but thought that several times I heard the 
placental souffle. About 3 p. m. she seemed to be sinking 
fast, the pulse sank rapidly to 18, and the respiration to 7 in 
the minute. I again bled her, and the pulse returned to 90, 
and the breathing became more frequent and less labored. 

" I had sent for medical assistance, and Dr. Gouley now 
arrived; we injected about three gallons of warm water 
against the os, in hopes of dilating it so as to apply forceps ; 
but it remained as rigid as a board. After partially dividing 
the OS on one side, one blade of a pair of rather heavy for- 
ceps belonging to Dr. Hyslop was introduced, but it was im- 
possible for either of us to introduce the other blade, and if 
even the fingers were passed up some distance by the side of 
the blade, the contractions were so violent as to cause the 
operator great pain by the compression of the fingers against 
the iron. We found that with these forceps it would be im- 
possible to deliver, so we sent for Dr. Elliot. With difficulty 
his forceps, which were much lighter and of very superior 
shape, were introduced by him, and the delivery accom- 
plished only after dividing the os on both sides. 



298 OBSTETEIC CLINIC. 

" The child was dead. A warm injection was adminis- 
tered, the bloodj urine again drawn off, an active purgative 
given, and cups applied freelj over the kidneys ; but the pa- 
tient did not rally, and died about midnight. The friends 
would not allow a post-mortem." 

It would have been an easier, and a justifiable task, to 
have used the perforator. But children often remain alive 
when the foetal heart cannot be heard. 

Still, with the methods now at our command, I scarcely 
expect ever to incise an os again. I have found it necessary 
in three cases, all seen in consultation, and two of which 
were cases of eclampsia and albuminuria. 

The ajjjplication of forceps in the hrim. In contracted 
conjugate^ head transverse and seized obliquely. — If the 
pelvis offer the most frequent example of deformity of the 
brim — contraction of the conjugate — as in the cases we are 
considering, and the child have reached term, it may be 
expected that the sagittal suture will present transversely, 
with the posterior fontanelle to one ilium or the other. Un- 
der these circumstances, the head is always seized obliquely— 
from one brow to behind the opposite ear; and although 
some slight differences may obtain in the site, the variation 
will not be great. The danger from this application is two- 
fold : 1. That of compressing the head, obstructing the cer- 
ebral circulation, and producing extravasation. 2. That 
the blades may cut or bruise the foetal tissues. These may 
be even badly cut or torn, and the eye may be seriously in- 
jured. It is not always easy to tell exactly how far the 
blade that passes over the brow may reach. The point may 
reach to the eyebrow, to the eye, and below the eye. If it 
reach to the eye, and strong compression be made, irrepa- 
rable injury may be inflicted. I know of a case where the 
eye passed within the fenestra and was guillotined, as it were, 
by the slipping of the instrument. The child, however, was 
dead before the operation was performed. 



PAEALTSI3 FEOM FOECEPS. 299 

Paralysis of the portio dura is not unfrequently produced 
by pressui-e of tlie blade over and behind the ear, Tliis is 
an unimportant accident, and, according to my experience, 
temporary in dm-ation. In the following case the paralysis 
lasted longer than I ever knew it to do before or since, but 
the pressure applied during the rotation was probably great, 
although the tissues were uninjured. It would be interest- 
ino' to know whether extravasation had occurred. 

CD 

Case 124. — Delayed labor ; forceps and conversion of a 
right occijpito-jposterior jgosition / facial paralysis of child 
and its recovery after convulsions. — Bellevue Hospital — 
Dr. Munson Coan, House Surgeon. 

Mary Fane ; second pregnancy ; aged 25 ; Irish. Labor- 
pains commenced in Bellevue Hospital, October 29, 1862, 
and were neither powerful nor frequent until the rupture of 
the membranes on the 30th, at 4.30 a. m. Having then 
augmented in power and frequency, the head descended to 
the inferior strait, but no further progress was made till 1 
p. M. The case was then examined by Dr. Elliot and diag- 
nosticated to be right occipito-posterior. The fcBtal heart 
was loudly audible over the anterior part of the abdominal 
wall as high as the umbilicus. The vagina was moist and 
of good temperature, woman robust and of good condition, 
pains feeble. Four hours more passed without advance. 
Caput succedaneum augmented. Foetal heart less distinctly 
audible, pains very forcible. The patient being brought 
under the influence of chloroform, Dr. Elliot applied forceps, 
and rotated the occiput under the symphysis. The child 
was delivered almost lifeless. It was revived by hot and 
cold affusion. Facial hemiplegia existed on one side, which 
had partially disappeared when the child left the hospital on 
the thirty-fifth day. On the 2d and 3d day of June it had 
several convulsions, which resembled those of trismus nascen- 
tium. 



300 OBSTETRIC CLINIC. 

Placenta remoyed by Dr. Elliot thirty minutes after de- 
livery. The litems contracted and relaxed alternately for 
two hours and a half, when some clots were expelled. 

The recovery of the mother was rapid and without an un- 
toward symptom. 

The head is seized in the oblique diameters. — ^Whether 
the pelvis be normal or not, before rotation of the head has 
occurred the forceps are commonly applied in the oblique 
diameters of the head, and of necessity in cases where the 
occiput is rotated anteriorly from either synchondrosis, even 
though they be subsequently removed, and reapplied in 
the bi-parietal diameter as soon as the position of the head 
will permit. 

It follows, therefore, that in difficult applications of the 
forceps it may be anticipated, as a law, that they will be 
applied over one of the oblique diameters of the foetal head. 
But the operator must always be able to tell beforehand the 
particular diameter embraced, and to say which brow is 
pressed upon, and where the traces will be found, if any 
exist. The inability to prophesy this fact demonstrates that 
the operator does not act with a clear idea of the situation. 
It may happen, in very exceptional cases, that the head is so 
high up, and so swollen, as to defy a diagnosis of its position ; 
and that neither the foetal heart, abdominal manipulation, 
nor conjoined pressure with one hand over the head above the 
pubis, and the fingers of one hand in the vagina, may con- 
duce to a certain result. In these exceptional cases tentative 
and explorative operations may have to be resorted to, and 
I^Tature may have to be " interrogated " in the delivery. 

Choice and uses of forceps. — The test use of the forceps 
is that of a tractor.— J^ot should they be allowed to com- 
press the head unless it is evident that traction alone will not 
suffice. Under theae circumstances compression with for- 
ceps offers the child a chance that the perforator can never 
offer, and therein lies its advantage ; but it is always a sad 



CHOICE OF FOECEPS. 301 

moment Tritli me wlieii compression lias to be resorted to, as in 
Cases 9S and 99. The chances of cerebral extravasations 
darken the future, and one ought to be very sure that trac- 
tions are insufficient before using compression. 

I am convinced that the addition of a sliding pivot to the 
handles of forceps is invaluable in graduating this compres- 
sion, and in preventing its risks. "With its aid, the exact 
amount of approximation of the blades desired can be de- 
cided upon before the tractions are commenced, and the risks 
of pressm^e, in the excitement and labor of the delivery, dis- 
missed from the mind. 

It dispenses with the necessity for the short handles which 
Radford and others have recommended, and allows them 
to be as long as may be desirable for a firm and powerful 
grasp. Cases will occur, however, though very exceptionally, 
of delivery of a large head, unfavorably seized, where the 
forceps are so widely separated that the pivot as ordinarily 
arranged may be scarcely sufficient, and where transverse 
bars, or an arrangement like Simpson's, at the articulation, 
may offer the best purchase. 

It is very desirable that forceps should occupy, as little 
space as possible. In very many cases a slender and narrow 
blade can be readily or cautiously passed, where but a frac- 
tional increase of size might render the application impossi- 
ble. Hence that instrument will have the widest range of 
usefulness which takes up as little room as is consistent with 
strength and the requisites for the head curve. All sharp 
edges are hazardous, and the extreme breadth, from one outer 
edge to the other of each blade should taper gradually tow- 
ard the handle, and not describe the bold convexity of Da- 
vis's and similar forceps. When the head is seized in the bi- 
parietal diameter nicely and satisfactorily, as pictured by 
Meigs in his work, that instrument is perfectly adapted to 
the average head, and neither the breadth of its blades nor 
the convexity alluded to is objectionable. But we have 
seen that this application is impossible in all but the simplest 



302 OBSTETEIC CLINIC. 

cases ; and wlien tlie head is seized in its oblique diameters, 
or the instrument cannot be advanced so as to grasp the 
whole head thoroughly, as happened in the following case, 
then the edge of one or of each blade may be free and liable 
to cut the vagina or the perineum. 

Case 125. — Forceps. 

I delivered Eose Swift with forceps, in Bellevue Hospi- 
tal, in February, 1858, on account of arrest of the head, prob- 
ably from exaggerated flexion. 

In applying the instrument, it occurred, from the posi- 
tion of the head, that the points of the blades reached the 
temples, just above the zygoma, and the handles, of com^se, 
not coming together, the pivot was adjusted to obviate risks 
from pressm-e. The delivery required strong effort, but left 
no trace. Prof. Barker was present. Child weighed 9 lbs. 
Living. Mother died from puerperal fever. 

It is impossible to devise a forceps which can be the best 
instrument for every case. One might as well attempt to 
make a shoe or a hat to fit every foot and every head. All 
that can be expected from a single instrument is that it 
should take up as little room as is consistent with strength, 
and its uses ; that it should afford every opportunity for pow- 
erful traction, without risking compression, until compression 
should be demonstrated to be unavoidable ; that it should have 
such a pelvic curve as may enable the operator to convert 
occipito and mento-posterior positions into anterior positions, 
provided no other conditions prevent ; that it should have no 
edges liable to project unduly and risk the laceration or cut- 
ting of maternal tissues. It is my belief that fenestrse di- 
minish somewhat the risk of injuring the head, especially the 
ear ; but it is comparatively unimportant whether they are 
present or not. Straight forceps can be used to deliver 
through the brim, and in the case of EHza Ford (jSTo. 99) it 
will be seen that they were apphed with equal facility. It 



CHOICE OF FOECEPS. 303 

is, liowever, mj conviction tliat a slight pelvic curve is desira- 
ble, and that it diminislies tlie risk of lacerating the perineum 
and vagina, in cases where this is projecting and rigid, and 
tractions have to be carefully made in the direction of the su- 
perior strait. Still this is a matter for individual choice, and 
it is true that the line of traction is always represented in the 
straight forceps by the axis of the handles, while allowances 
must be made in the others for the curve of the instrument. 
On the whole it is my conviction that a slight pelvic curve 
will render the instrument better for the beginner. The ex- 
pert needs no advice. 

There is an advantage in a lock which can readily be 
fastened, and if its security receive the additional guaranty 
from the pressure of one hand on transverse bars at the artic- 
ulation, or from a finger pressing upon it from above, the 
great requisites of facility and strength are combined, and 
the more accurate adaptation of Bruninghausen's or Levret's 
lock dispensed with. 

Such, in brief, seem to me the requisites for a forceps 
adapted to the great majority of cases. It cannot be the 
best for all, and no one can be devised that is free from 
criticism. Yery much depends on the way in which the 
instrument-maker tempers the metal, and follows the model. 
This is so often neglected, that every man who has devised 
an instrument must have seen specimens for which he would 
regret to be responsible. Hence, although there have been 
more forceps designed than are really needed, and although 
no material improvement can be suggested in them, there is 
good reason for believing that special instruments can be 
better procured in cities where their manufacture can be 
supervised by those who feel a professional interest in the 
result. 

Having used myself some fourteen different styles of for- 
ceps (not including two applications of Simpson's air-tractor), 
my preference was given to that of Prof. Simpson ; but about 
ten years ago, Mr. Ford, of this city, 85 Fulton Street, hap- 



304: OBSTETEIC CLINIC. 

peiied to be present at a lecture of mine in whicli I sketclied 
tlie qualities which I should like to combine in a forceps, 
and offered to make a model of the instrument which I had 
described. He succeeded in doing so, and it has proved useful 
and satisfactory to me, as well as to manj others. It is well 
known in this city, and seems to me as applicable now in the 
great majority of cases as it seemed ten years ago. 

All slender forceps are liable to lose their liead-curve in 
time if subjected to great tractive force, and I have been 
surprised that mine have stood the test so well. I once saw 
such an accident happen in the hands of Dr. Shekleton, 
master of the Dublin Lying-in Hospital, where they did not 
exaggerate the applicabihty or tractive powers of the instru- 
ment. It has happened to me on one occasion with a pair 
of Simpson's forceps, purchased from Weiss, in London, which 
had previously withstood many a hard bedside trial. 

Case 126. — Illustrative of great tractive force '^ forcej^s ; 
perforator. 

Called in consultation with Dr. Freeman to Mrs. M , 

a twin, whose sister had died after her second difficult labor ; 
this one, a primipara, 26 years of age, at full term, had 
been in hard labor for eighteen hours. Second stage. — Os 
fully dilatable, soft parts cool, head presenting the second of 
l^aegele, right occip.-post., and wedged in superior strait, 
after commencing rotation ; no foetal heart appreciable, but 
strong uterine souffle ; Simpson's forceps, preceded by chloro- 
form and baptism; tractions^ until 07ie hlade straightened 
GOirvpletely. Another pair; no better success. Perforator 
and crotchet now used; hard work. Finally replaced the 
forceps around the diminished head, and effected its delivery. 
Shoulders could only be extracted with the blunt-hook; 
tight work even with the breech. Child must have weighed 
fully thirteen pounds. I saw the mother afterward, when she 
was doing well, and I believe that she has done well since. 

Remarlcs. — My reason for making such great efforts with 



USES OF rOECEPS. 305 

the forceps, even Trlien tlie foetal heart was entirely inaudible, 
was the fear that its position might render it inaudible ; for 
who has not known the foetal heart in the presentation of 
the post. font, to the sac.-il. sjn. become andible after rota- 
tion alone ? 

A fact illustrated in the following case. 

Case 127. — Powerless labor with rigidity ; ergot; forceps. 

Dr. M. sent for me on the 15th of ITovember, 1862, to 

Mrs. O , a primipara, aged 30. The labor had then 

lasted sixty hours, and was ushered in by rupture of the 
membranes and escape of the liquor amnii. The causes of 
delay were the unsatisfactory character of the pains and the 
rigidity of the soft parts. Ergot had latterly improved the 
character of the pains and advanced the head, but the patient 
was tired, and implored relief. Yaginal examination dis- 
closed a left occipito-anterior presentation of the head, with 
the movement of descent completed, Yagina cool and 
moist ; vulva much swollen. The coccyx was quite unyield- 
ing, though not anchylosed, nor yet pressed upon by the head ; 
perineum rigid and tense. Neither Dr. M. nor I could satisfy 
ourselves that we heard the foetal heart. Under these circum- 
stances it was decided to apply forceps, in the belief that 
thereby the child, if then alive, would be saved, and that many 
hom'S of useless suffering would be spared the mother. As 
soon, therefore, as Dr. M. had thoroughly and promptly 
brought the mother under the influence of chloroform, I de- 
livered her without lacerating the perineum. The child was 
a large-sized boy, and required alternate hot and cold bath- 
ing, etc., to revive him. Both did well. 

There are few facts which impress the beginner more pow- 
erfully than the tractive force which can be advantageously 
and properly used in diflicult forceps cases. An inexpert man, 
not certain that he has grasped the head properly and firmly 
— ^not certain that his tractions are made in the proper axis — 
20 



306 OBSTETEIC CLINIC. 

not sure that he is delivering in obedience to the laws of the 
mechanism of labor — and not certain that he conld stop his 
tractions instantly at the &st commencement of slipping — 
has no right to put so much force on the instrument. 

But the man alive to all these indications — sm^e of the 
position of his blades, and of the necessity for great force — 
pulling only with his arms, and not "with his back, and wide 
awake all the time — may find that just such tractions are the 
only ones which can terminate a labor without recom-se to 
embryotomy ; and that just such tractions, repeated again if 
necessary, may alone justify the subsequent resort to embry- 
otomy. 

Such cases are very exceptional, and it is of such that we 
are speaking ; and even then the alternative may be most 
horrible, and only bearable when we know that delay will 
certainly kill the child and endanger the mother. 

Case 128. — Forcej^s / ])erf orator / hivpacted head. 
Saw a negress, in 1860, in consultation with Dr. 



large and well-ossified foetal head had become fij^mly impacted 
in the pelvis. Foetal heart beating. Used all the traction 
that I could with forceps, without advancing or moving the 
head one iota, when I perforated and delivered. Mother 
recovered. 

With the exception of comparatively simple cases, in 
which the delivery can be readily effected, and must be very 
prompt to insm-e the successful result of the operation, it is 
better that the tractions should be made slowly, and even 
that intervals of rest should be given, when the blades may, 
perhaps, be also allowed to separate somewhat from each other. 
This method is peculiarly applicable in delivering through a 
rigid cervix, or rigid soft parts and perineum, as it imitates the 
behavior of a natural labor, and allows time for dilatation. 

I have seen several cases in consultation where the diffi- 
culty met with by the practitioner in delivering, both with 



USES OF FOECEPS. 307 

tlie forceps and tlie crotchet, lias arisen from pnlling too 
speedily in the direction of the inferior strait. We cannot 
pull a head throngh the pnbes, it may hng the corner, bnt 
it mnst go aronnd. 

There is another tendency against which beginners mnst 
be warned, viz., an exaggeration of the side-to-side move- 
ment in traction. "We are tanght that forceps advance the 
head by direct traction, and by a double lever side-to-side 
movement. And so they do. There is also once in a while 
an advantage in starting a head by moving the handles a 
little np and down before di-awing npon them. But I have 
known more than one instance in which the fulcrum has 
been made of the descending rami, and the tissues on each 
side have been cut by pressure of the instrument. Yaginal, 
not perineal lacerations from forceps, are more liable to oc- 
cur than is generally known, and nothing marks the expe- 
rienced operator more than his care to avoid these lesions. 

When a man is called to complete a delivery where for- 
ceps or other instruments have been previously used inef- 
fectually, it is a very good plan for him to make a careful 
examination of all the maternal and foetal tissues within 
reach, and to 'Rx the responsibility for any existing lesions 
before he proceeds to attempt the delivery himself. As a 
ride these lacerations heal up nicely, and the tissues mould 
themselves again properly, but they are foci for puerperal 
inflammations, invite cellulitis, may result in cicatrices, and 
should be carefully prevented when possible. . 

Case 129. — Forcejps and lacerations of the vagina '^ sub- 
seqicent fo7'ceps delivery of a living child. 

I was sent for in consultation to a multipara, attended by 
two excellent practitioners, without, however, a large expe- 
rience in operative midwifery, and reached the house a little 
before Dr. T. F. Cock, who had also been summoned. Foetal 
heart beating. Right occipito-posterior presentation. The 
forceps had been applied but had failed to deliver. On each 



308 OBSTETRIC CLIXIC. 

side of the Tagina, opposite the junction of the ischiatic and 
pubic rami, were lacerations, evidently produced by pressing 
the forceps too fii*mly against the bones in an exaggerated 
side-to-side lever movement. Having applied the forceps, 
and rotated the occiput to tlie pubes, I delivered a living 
child, and the mother subsequently did well. Chloroform. 

Other cases could be adduced illustrative of these facts. 
It is certain that the error is most liable to be committed by 
the man who has most thoroughly mastered the theory of 
forceps, and has not yet used them much in practice ; and I 
have often noticed this tendency in the fet operations of 
friends of mine. 

The beginner must never forget that the perineum dis- 
tends and advances greatly with the advance of the child's 
head, unless in multiparas with great relaxation, or deficient 
perinea. When the perineum is rigid, the head must be ad- 
vanced slowly and in the dii-ection of the curve, hugging the 
pubes, so that at the last the handles of long forceps with a 
pelvic cm*ve touch, or almost touch, the mother's abdomen. 

It is very rarely necessary to remove a slender pair of 
forceps well applied. They can come with the head. I 
have only done so in three or four instances. By pressing 
the fingers in the rectum, the operator can appreciate not 
only the relations of the head to the perineum — and possibly 
advance the head, or even deliver it with the fingers alone— 
but he can appreciate the relations of the forceps to the soft 
parts when the head is seized obliquely. An invaluable pre- 
caution, which I rarely omit. 

Case 130. — Forceps / tedious labor from rigidity / ad- 
vantage of toucMng the head and forceps' Uades through the 
rectum during delivery. 

Mrs.- — -, IsTovember, 1860, aged 24; primipara; right 
occipito-posterior position. Male child, living. Mother did 
well. Yery little liquor amnii. One of the " diyest labors " 



USES OF FOECEPS. 309 

tliat I ever saw. Tried flax-seed tea, wliite of egg, lard, oil, 
glycerine. Yagina and perinenm rigid and unyielding. 
Chloroform for abont ten hours to a moderate extent. Pos- 
terior fontanelle came at last to the right acetabulnm, and 
then remained stationary for several honrs. Prof. Gihnan 
then saw the patient in consultation, and recommended for- 
ceps, which I applied. The perineum very rigid. Anns widely 
open, as often happens in primiparse. Delivered without 
lacerating the perineum, deriving great assistance from intro- 
ducing two fingers well within the rectum to make sure of 
the relations of the forceps to the head and the soft parts. 

Let me not be understood to imply that the perineum can 
always be saved fi^om laceration. This will happen when 
the camel can go through the eye of a needle. But dispro- 
portion of size is not the only cause. One may sometimes 
clinically suspect a given perineum of a tendency to lacerate 
despite all precautions, and find his forebodings true, al- 
though he cannot explain them satisfactorily. The relations 
of the perineum to the curve of certain sacra sometimes in- 
fluence the result. 

Case 131. — Forcejps for delay ; still-lorn child / death 
of child and difficulty in delivery helieved to have heen due 
to the encircling of the neck hy the funis. 

Margaret Bradley ; single ; aged 26 ; first pregnancy. 
In labor from February 12, at 2 p. m., until February 15, 
1861, at 1.45 p. M. Presentation L. 0. A. First stage forty- 
eight hours ; second, twenty-three hours and forty minutes ; 
thu'd, '?iYQ hours. Still-born male child, weighing seven and 
a half pounds. Bellevue Hospital, Drs. Erskine Mason and 
Eives, House Physicians. 

This patient stated that the waters had dribbled for sev- 
eral weeks before delivery, though great confidence was not 
placed in any of her assertions. The foetal heart was last 
heard in the evening of the 14:th, and could not be detected 



310 OBSTETEIC CLINIC. 

in the careful examinations made subsequently to tliat time. 
"No movement of the child could be appreciated for twenty- 
four hours before delivery. As it was evident that there was 
nothing more to be expected from the uterine efforts, I de- 
cided upon delivering her with the forceps. The three days 
of labor had not produced exhaustion, nor evidences of danger 
to maternal tissue, but the head absolutely failed to advance. 
The hand introduced well within the vagina showed that the 
head was in the superior strait partially through the brim, 
and not wedged, impacted, nor arrested by any condition de- 
pending on faulty ratio of size between it and the maternal 
pelvis, or by any cause which could be appreciated. The 
mother's abdomen seemed of greater size than is usual with 
children of this weight. The forceps were readily intro- 
duced in the customary manner in such positions — one blade 
in front of the left synchondrosis, the other behind the right 
acetabulum, and readily locked, though their relations to the 
oblique diameter of the well-developed foetal head required 
that the pivot should be pushed to the highest hole. The 
first tractions were promptly successful in completing descent 
and rotation, but they had to be very forcible to draw the 
head well on the perineum. 27iis appeared to me to te a 
jperineum very likely to tear, and I accordingly withdrew the 
forceps in accordance with Pugh's and Madame Lachapelle's 
advice (though in my experience this is of the rarest neces- 
sity), and completed delivery of the head with the aid of two 
fingers in the mouth and firm traction on the superior 
maxillary bone. The funis was twice around the neck and 
entirely pulseless, so that no doubt was left concerning the 
death of the child, and I drew forcibly on the head with- 
out advancing the body. Introducing my hand within the 
vagina, I found the shoulders in the brim, and drew down 
the posterior arm with much effort, fracturing it designedly 
to facilitate the manoeuvi-e, after which the delivery was 
effected and the placenta came away almost immediately. 
The perineum was now found lacerated in a jagged manner, 



USES OF rOECEPS. 311 

so as to slightlj involve tlie lower part of the septum. This 
occiu-red subsequently to the withdrawal of the forceps, and 
was immediately sewed up with silver wire, but without the 
slightest effort at repair. The action of the sphincter ani was 
entu'ely unaffected. The scalp, face, and ears of the child 
were livid from congestion, the marks of the funis white, and 
the skin below of the ordinary color. 'No examination made 
of brain. Funis one yard long. 

In this case it has always seemed to me that the delay 
occurred from retention by the funis, the gradual tightening 
of which dm*ing the labor I believe to have caused the child's 
death. In support of this view, I point to the evidences of 
strangulation observed in the child, and the steady increase 
of tractive force required as the foetus was advanced. The 
difficulties depended on no disproportion of size or faulty 
position of head, shoulders, arms, or any other part of the 
body, as these points received my full attention during the 
manipulations described, nor was there any spasmodic irreg- 
ular contraction of uterine fibres. Especially did I examine 
the position of the arms preparatory to deciding on bringing 
one of them down in the manner described, as the displace- 
ment behind the neck was forcibly brought under my obser- 
vation by the kindness of Prof. Simpson in taking me to the 
case described in the Edinburgh Monthly for April, 1850. 
The length of the cord in this case would seem to have been 
sufficient for a natural delivery, but it is probable that even 
a funis of such length may prove a cause of delayed labor. 
It requires about twenty inches of funis to furnish two coils 
for the neck, and the remainder may very well be so dis- 
posed around the child's body as to impede the advance of 
the head, especially if the placenta should be attached to the 
fundus uteri. The mother died September, 1861 (seven 
months after), in the hospital, from an attack of diarrhoea, 
her health never having been completely restored after her 
confinement. There is no history of her case. 



312 0B5TETEIC CLIXIC. 

In manv eases a sliglit laceration of the perineum bj tlie 
head is converted into a larger, or a formidable one by the 
sboiilders. or by subsequent manipulationSj lience om' cai'e 
should be redoubled at these times. 

I have often derived advantage from, pressing back the 
head or shoulders with the fingers imder these cii'cunistances, 
and antesthetics are of great service. 

Application of the ard-erior IJade. — "We are taught to car- 
ry the anterior blade to its place by a spii'al sweep, introdu- 
cing it in front of the synchondrosis or in a neai'er situation 
and then gently moving it around into position. In 1S53, 
the late Dr. John C. Cheesman taught me to carry it directly 
behind the acetabulum. Trithout any preliminary. By this 
method I have often applied forceps promptly and satisfacto- 
rily when the sphal sweep would have been impossible or 
very diSicult, or an additional risk to the maternal tissues. 
Xumerous examples of this practice are scattered through 
this volume, and I have taught the same for fourteen years 
in many clinical cases. The leg^s should be well separated, 
tlie fingers carried as a sheath to the position, the handle de- 
pressed, and the blade carried directly to its site. The prac- 
tice is not recommended as 'one more desirable as a mle, but 
as convenient in some cases, and the only possible plan in 
others. 

Position of the patient in forceps operations. — Excej)t in 
rai'e and very exceptional cases my patients ai'e always 
placed on their backs for forceps application, as is the cus- 
tc>m in this country and in France. In my opinion, after a 
trial of the side, and observations abroad — ^including a resi- 
dence of six months as resident pupil in the Dublin Lying-in 
Hospital — ^the operator thus has the patient under much bet- 
ter conti'ol, and she is much better placed for the auEesthetic, 
and for other assistance. 

In the following case the peculiar position of the patient 
mioht have occasioned injmy to the perineum. 



USES OF FOECEPS. 313 

Case 132. — Force;ps for delay ; cord tightly around neck. 

At 3 A.M., July 30, 1866, I was called to Mrs. byDrs. 

E. and H. She was a primipara, aged 27, well formed and 
healthy. The discharge was rather greenish, but her condi- 
tion good in eyerj respect. There had been no ad^yance for 
some hours, although the pains were strong and good. She 
had been in labor since the morning of the 28th, and the 
membranes had ruptured on the morning of the 29th. All 
parties were tired out by the strain of two nights' watching. 
Foetal heart beating on the right side. Head presenting. 
R. O. A. Moyement of descent not yet completed. One 
foot to be felt within the brim to the left. A small pendu- 
lous polypoid tumor on the upper wall of the yagina. The 
patient being brought under the influence of chloroform, I ap- 
plied forceps and deliyered without difficulty, though I could 
not understand why it was necessary to so exaggerate the 
upward traction until I recognized that it arose from the fact 
that, as the bed was yery low, those haying charge of the" 
patient's knees lifted them so high as to produce this result. 
Such an accidental position might well lead to injury of the 
perineum if not appreciated in time. The child was a boy 
of large size, the cord of a greenish color, and tightly around 
the neck, and demanded fully three-quarters of an hour of 
labor before respiration was established. 



CHAPTER XI. 



EMBEYOTOMT. 

Preliminary considerations. — Difficulties attending tlie proof of the child's death. 
— Case: Forceps in lingering labor twice applied. — Preliminary baptism. — • 
Case : Breech presentation ; paralysis of sphincter ani coexisting with foetal 
heart-sounds; fillet after death of child. — Case: Forceps for exhaustion of 
mother ; approximation of ischiatic spines ; liquor amnii colored with meco- 
nium. — Case: Forceps for cessation of foetal heart-sounds. — Case: PeMe 
presentation of a child weighing fourteen pounds ; remarkably small nates ; 
blunt-hook. — Case: Arm presentation ; cephahc version ; child supposed to 
be dead; no reflex movements; fcBtal heart inaudible; meconium present 
in great quantity in the discharges ; child subsequently bom alive. — Case: 
Forceps for delay and danger to child ; difficult auscultation. — Choice of 
instruments for embryotomy. — Perforator. — Cephalotribe. — Craniotomy. — 
Forceps. — Blunt-hook. — Introduction of the perforator. — Case: Perforation 
in a contracted conjugate. — Case: Contracted outlet; forceps; perforation. 
— Case: Forceps and perforator for deformity of brim. — Case: Arm in the 
vagina ; head above to the right ; child dead ; perforator ; brow had origi- 
nally presented. — Case: Kupture of uterus; removal of placenta and ver- 
sion; perforator. — Case: Eclampsia in sixth or seventh month ; induction 
of labor with douche; venesection; purgatives; delivery with a crotchet 
made of strong wire. — Case : Fatty degeneration of foetus and placenta at 
term with history of previous labor. — Case: History of her previous labor. 
— Case: Twins — one living, one dead; fatty degeneration of the latter's 
placenta. 

jPreliminary considerations. — ^Whenever in a difficult 
labor the child can be proven to be dead, and the labor can 
be facilitated by embryotomy, this operation should be pre- 
ferred. 

Whenever there exists a hope that the child may still be 
living, embryotomy must not be resorted to, unless other 



e:mbrtotomt. 315 

elective operative measures have failed ; and perhaps have 
failed in more than one trial, l^or even then is embryotomy 
justifiable unless the consultation are convinced that further 
delay must certainly preclude every chance of safety for the 
child, and very seriously endanger the maternal tissues or 
life. ' 

There are, however, cases of labor where the child is 
certainly known to be dead, and yet the operator is abso- 
lutely confident that he can deliver an unmutilated child 
with forceps, without adding to the mother's risk. And 
this may be specially true of the expert. There are also 
cases in which the physician is confident that he pereonally 
is better fitted to dehver with forceps than to use the per- 
forator. In these contingencies a man must judge for him- 
self, and take the responsibility. 

This practice may, however, be abused. There are men 
who are so reluctant to use the perforator, that they will 
always prefer operations more dangerous to the mother when 
the child is proven to be dead. This extreme is a safer and 
a better one than the too ready resort to the perforator, 
which has characterized some practitioners and schools ; but 
it is still an error. If a man undertakes these operations, he 
must perform those which are for the benefit of the patient, 
rather than those which are more agreeable to himself. 

Difficulties attending the jproof of the chilcTs death. — The 
beginner cannot impress too strongly on his mind the clinical 
fact, that children are often living when the foetal heart can- 
not be heard ; when foetal movements cannot be excited by 
the hands on the abdomen or within the uterus ; when the 
child will not suck the finger put within its mouth, and 
when the anus will not contract around the exploring finger. 
The foetal heart may beat, but be inaudible from debility, 
change of position, and character of objects intervening be- 
tween it and the mother's abdomen. Greenish vaginal dis- 
charges, and the presence of meconium in large quantities 



316 OBSTETRIC CLINIC. 

tlierein, in cases where the head presents, do not prove that 
the child is dead. Examples of all these facts are given in 
this volume, and force us to the conviction that the perfora- 
tor is often resorted to with the clearest convictions for its 
desii-abilitj while yet the child lives ; and these facts show 
that we should most reluctantly admit the fact that the child 
is dead. In many cases, as in that of Mary Foy (ISTo. 100), 
this may be demonstrated by the pulseless condition of the 
funis. In estimating this condition, time should be allowed 
for such careful examination as may show the fact to be un- 
doubted ; and it is well, if possible, that others should appre- 
ciate the same. 

In all cases, however, in which, while the funis is pulse- 
less, there is yet a hope that these pulsations have recently 
ceased, and that prompt delivery of an nnmutilated child 
may be effected by other methods, the perforator must not 
be used until these shall have been faithfully tried. 

In some cases where a thorough but ineffectual trial of 
the forceps has been made, and further time then allowed, the 
labor may terminate spontaneously, when it may be objected 
that the forceps were applied without necessity. Without 
denying that these cases occur, such a contingency should not 
weigh with a competent man who has conscientiously done 
what he believed to be the best for the interest of the two lives 
confided to him. 

Case 133. — Forceps in lingering labor twice applied. 

Dr. sent for me in consultation in April, 1859, to 

Mrs. , a primipara, about 20 years of age, who had been 

in labor for two days, the membranes having been ruptm'cd 
nearly thirty-six hom'S. The posterior fontanelle was to the 
left acetabulum, the movement of descent not completed, 
rotation unaffected, foetal heart beating, vagina cool and 
moist, patient fatigued. The patient having been brought 
under the influence of chloroform by Dr. , I applied the 



DIFFICrLTT m PROVING THE CHILd's DEATH. 317 

forceps with, tlie coucayitj of tlieir pelvic curve to tlie left, 
rotated, and delivered a living female child of large size, 
which did vrell, as did also the mother. In this case an inef- 
fectual effort at delivery with forceps had been made before 
my arrival, and it was believed that perforation would proba- 
bly be required. The case illustrates the advantages often 
obtained by repeated trials of forceps. 

Preliminary 'bwptism. — ^Wherever the parents of the 
child are Roman Catholics, and believe that baptism of the 
unborn child is essential, the operator should see that a pre- 
senting part of a living child be baptized before a dangerous 
operation is undertaken, since, according to the Roman 
Catholic Church, this can be done by a layman ; and it is 
the duty of the physician to respect the religious convictions 
of his patients. 

This advice is desirable in this country, where all varie- 
ties of religious creeds are found, and enjoy an equal inde- 
pendence. In Catholic countries such practice is the rule 
and not the exception. Depaiil gives the history of a case 
in whicb the preliminary baptism was performed as a matter 
of course, and the parents informed thereof by the attentive 
practitioner. The situation may be appreciated when he 
found tbat baptism had been carefully administered to the 
offspring of Israelites. 

Case 134. — Breech presentation / paralysis of sphincter 
ani coexisting with foetal heart-sounds; fillet after death of 
child. 

The late Dr. Winchell sent for me on the 11th of May, 

1863, to Mrs. L^ , in labor with her second child. The 

first labor had been very long and tedious, and she had final- 
ly been delivered with forceps of a dead child. On this 
occasion the waters had broken at 5 a. m., May 11th, when a 
breech presentation was recognized, the sacrum being turned 
to the left sacro-iliac synchondrosis. Child male. Pains 



318 OBSTETEIC CLINTC. 

good. Woman very stout. At 8 p. m. the doctor sent for 
me, saying that lie tliouglit interference would be necessary 
to terminate the labor. 

I found that the maternal passages were moderately dry, 
but not hot ; maternal pulse and condition good ; moderate 
amount of water in the bladder. Foetal heart loas heating^ 
hut the rectum did not at all contract lohen the finger was 
introduced within the sphincter. Scrotum greatly enlarged. 
Breech entirely in the superior strait. Movement of descent 
not completed. 

The situation was in some respects peculiar. It was the 
first time that I had ever been able to recognize the foetal heart 
when there coexisted such paralysis of the sphincter ; indeed, 
I had been accustomed to consider such paralysis as one of 
the evidences of death. Interference was not needed for the 
mother's sake, and I gave it as my opinion that we could 
scarcely hope to deliver the child without mutilation ; and 
that as the pains were good, we might better wait longer to 
see whether I^ature could do better. It seemed to me that 
the paralysis of the sphincter, although not an evidence of the 
child's death, was yet a strong evidence of its very exhausted 
condition, and gave but a feeble hope of its ability to live, 
though it were born alive, and I could not avoid the convic- 
tion that with the history of the previous labor, the dm-ation 
of this labor, the size of the child, the size of the mother: — 
padded as she was with fat — ^neither the hands nor the forceps 
would suflS.ce. Accordingly we separated. The labor-pains 
continued strong until 4 a. m.. May 12th, when, as there had 
been no advance. Dr. W. gave her forty drops of McMunn's 
elixir of opium, and she had some sleep. At 10 a. m. I was 
called again, and found that there had been no advance. 
Maternal passages neither hot nor swollen. 'Eo foetid dis- 
charge. "We decided to interfere, and I proceeded to intro- 
duce a fillet made of a strip of linen three inches wide, and 
about twenty-eight inches long. This was well soaked in 
oil, and folded so as to diminish its width by one-half. Some 



DIFFICULT PELVIC PEESENTATION. 319 

five or six inclies of one end being rolled into a ball, I tried 
to pass it over the anterior tliigli (left), but it was impossible 
to pass any thing whatever over that thigh, so tightly was it 
pressed against the anterior wall. It was with a great deal 
of difficnltj that I succeeded in getting it around the poste- 
rior (right) groin. 

Dr.' Meigs says in his " Obstetrics," second edition revised, 
page 495 : " The efficacy of its (the fillet's) action would 
be greatly enhanced by placing it on the groin that is far- 
thest from the pubal arch ; but that is a feat of dexterity 
that can rarely be performed." 

It was performed in this instance, but I do not see the 
advantage of choosing the posterior thigh. On the contrary, 
it seems to me that, in obedience to the mechanism of labor, 
we should always seek to advance the anterior natis the first, 
as is always done in a natural labor ; and furthermore, that 
we can thus most successfully di'aw the whole trunk in the 
direction of the superior strait when the breech is situated 
therein. 

We found it difficult to bring down the breech, and 
relieved each other in our tractions with the fillet, but nei- 
ther fractured nor dislocated the bone, nor lacerated the 
skin of the groin. As the breech descended, it turned spi- 
rally, so that the right trochanter, which had originally been 
the posterior one, came out under the pubes. The second 
arm had to be delivered with a blunt-hook, but was not frac- 
tured. The head was then found to be situated transversely, 
with the chin above the linea ilio-pectinea, and somewhat 
toward the left sacro-iliac synchondrosis. The child was dead. 
Forceps would have been inoperative if it had been living, 
as there was no room for their introduction ; and the blunt- 
hook having been securely fastened in the mouth by Dr. 
Winchell, he brought it down and delivered. The pla- 
centa was on the anterior face of the uterus, and there was 
some hemorrhage after delivery. Ergot and irritation of the 
inner part of the cervix caused contraction. The abdomen 



320 OBSTETEIC CLINIC. 

was so yerj stout as to cause some difficulty iu manipulating 
the uterus. I believe tliat tlie mother did well, or I would 
liave seen her subsequently. 

Case 135. — Forceps for exhaustion of mother ^ approxi- 
mation of ischiatic spines; liqiior amnii colored with 
meconium. 

February 8, 1861. — Bellevue — Dr. Erskine Mason, House 
Surgeon. 

In this patient — a primipara — no advance had been made 
since the evening before, membranes unruptured, foetal heart 
beating, head presenting first position, descent not completed, 
soft parts in good condition. The mother was much ex- 
hausted, feeble pulse, hoarse voice, suspicions of phthisis. 
Ruptm-ed membranes, liquor amnii scanty, liTce diluted 
molasses, no odor, probably colored with meconium. On 
examination, the spines of the ischia were found to project 
unduly ; first blade very reacdly passed ; second had to be 
carefully placed in position behind the right acetabulum by 
direct application, the customary spiral movement being 
impossible. To deliver, it was necessary to slip the pivot 
down two holes below the point where I had first placed it, 
as some compression was necessary. Child born living; 
weight, seven and three-quarters pounds ; somewhat marked 
and bruised by the blades. ISTo injury to perineum. March 
Qth. — Both have done perfectly well. Traces of forceps dis- 
appeared. 

In this case stimulus was given before Dr. Eives brought 
her under chloroform. 

In the following case the child would have been still-born 
had I not been warned by the history of the three previous 
still-births. It is only when the waters are evacuated, and 
the physician is sm*e that the intensity or the situation 
of the foetal heart is not altered by a change in the position 
of the foetus, that a sudden and permanent cessation of the 



DIFFICULTY m PEOYING THE CHILD's DEATH. 321 

heart-sounds may be accepted as indicating the danger or 
death of the child. 

Case 136. — Forceps for cessation of foetal heart-sounds. 

Mrs. K engaged me in October, 1859, to attend her 

in her fourth confinement. Her three children had been 
still-born at term, and two had presented the breech. On 
examination I found that the head presented, and the foetal 
heart-sounds were distinct. Within a fortnight the labor 
commenced, and proceeded without any thing worthy of note 
— occiput anteriorly, inferior strait reached — until suddenly 
the foetal heart-sounds, which I had been watching atten- 
tively, grew faint and stopped. Without waiting for chloro- 
form, I immediately deliyered with forceps, and succeeded 
in reviving a feeble but well-developed child. Unfortu- 
nately, however, it died at the age of two months, from 
pneumonia. It is my conviction that many still-births might 
be prevented by more frequent examinations of the foetal 
heart than are customarily made during the progress of 
labor. 

Case 137. — Pelvic presentation of a child weighing four- 
teen pounds I remarkably small nates / delivery with Hunt- 
hooh 

In I^ovember, 1860, 1 presented to the class at Bellevue 
a still-born female child, weighing fourteen pounds. The 
mother had an ample pelvis. It was her eighth pregnancy, 
and she believed that she had carried the child ten months. 
I was called in consultation to the case on account of a non- 
advance in labor. The membranes had ruptured before the 
presentation could be made out. On examination I found a 
pelvic presentation, the sacrum being toward the right ace- 
tabulum, and the dorsum of the child toward the abdomen 
of the mother — the most frequent form of pelvic presenta- 
tions. 

21 



322 ■ OBSTETEIC CLINIC. 

The uterine efforts appeared to be powerful, and the de- 
lay seemed the result of over-distension of the uterus. The 
great bulk of whatever was contained in the uterus was as- 
certained, bj external examination of the abdomen, to be on 
the left side. So that, assuming the existence of only one 
child in the uterus, we had the anomaly of the presentation 
as described, the nates small absolutely, the balance of the 
child relatively immense, and its great convexity on the left 
side ! Images of course arose to the mind, of twins, and 
monsters of every kind : double children, children with two 
heads, hydrocephalic children, children with ascites, etc. 

Advised delay. 

On the next morning, there being no change and the pa- 
tient's condition being good, delay was no longer considered 
advisable. The presenting part was found, on examination, 
to be just dipping into the superior strait. Therefore (chlo- 
roform having been administered) introduced my right hand 
and pulled upon the anterior leg. In this way, and with the 
finger in the groin, I pulled and tugged and toiled with all 
the force at my command, without any advance in the way 
of delivery. I then had recourse to the blunt-hook in the 
groin, and, after long and wearisome effort, succeeded in 
drawing that part of the child down to the vulva. The leg 
of that side was, by that time, pendulous merely by a portion 
of the skin. The child was, of course, long' since dead. Sim- 
ilar efforts drew down the other side. The head passed 
without instrumental assistance. 

In this case the absence of contractility of the sphincter 
ani (the heart being inaudible) was accepted as a sign of 
foetal death, as at. that time I believed it to be. As the child 
lay upon the table, the smaU size of the nates appeared in 
striking contrast to the great bulk of the body. 

Case 138. — Arm joresentation ^ cephalic version; child 
siijyposed to he dead; no reflex movements ; fmtal heart in- 
audible ; meconium present in great quantity in the dis- 



323 

chargers / siibseqiiently lorn alive without assistance. — Belle- 
vue — Br. Amalile, House Physician. 

Julia Larrey, admitted to the 1 jing-in wards of Belle vue, 
April 11, 1S66, at 10 p. m. Slie is married; 28 years old; 
second pregnancy, the first resulting in a miscarriage. Labor- 
pains had commenced at 8 p. m. Foetal heart audible a little 
to the left of the abdomen. Os uteri not sufficiently dilated 
to allow the presentation to be recognized. After the waters 
broke, the right hand was found presenting, and the vertex 
could be felt a little toward the right. Dr. Amabile called 
me to this patient at 11 a. m., April 12th, and informed me 
that the foetal heart could not be heard after 8 a. m. The 
right arm was in the vagina ; long axis of uterus normal. 
Head recognizable above the pubes. Meconium present in 
great quantity in the discharges. No reflex movement of the 
head. I proceeded to push up the arm and bring down the 
head. In doing so, the right foot was recognized above the 
brim, and no reflex movement could le produced thereof 
Both were pushed up and the head brought into the brim of 
the pelvis by external pressure. The head was found to pre- 
sent in the right occipito-posterior position, and before leav- 
ing it I flexed it thoroughly. The assurance given me that 
the foetal heart was inaudible, and the other conditions de- 
tailed, decided me to leave the case to nature, and I supposed 
•that the child was dead and did not listen myself. 

The patient came well from under the anaesthetic, the 
pains came on, and she was delivered of a healthy child three 
hours after. Both did well. 

Case 139. — Forceps for delay and danfiger to child ; diffi- 
cult auscultation. 

Bellevue Hospital, Dr. Levi Warren, House Physician. 
Catharine McDermott ; Irish ; aged 30 ; first confinement ; 
menstruated last, December 1, 1855. Labor commenced 
October 10, 1856, at 2 p. m., and was terminated at 3 p. m.. 



324 OBSTETEIC CLIXIC. 

October 12tli. First stage, fifty-two lioiu's; second, eiglit 
and a half hours ; third, fifteen minntes. 

Strong labor-pains for fiftj-two hours, which were, how- 
ever, inefiectual. The os uteri, although not rigid, would 
then only admit the tips of the fingers. The membranes 
then ruptm-ed, when the head was found presenting in the 
first position, and a few strong pains drove it down to the 
inferior strait, where it remained without advance for eight 
and a half hom^s, notwithstanding strong continued uterine 
efforts. At this time the house staff could not distinguish 
the foetal heart, and Dr. Warren sent for me. Having recog- 
nized feeble pulsations, I applied the forceps and delivered a 
living female child weighing eight and a quarter pounds. 
The perineum was slightly torn, but healed perfectly, and 
the patient left on the 1st of I^ovember, perfectly well. 

Choice of instruraents for emhryotomy. — Perforator. — I 
have tried the various modifications of Smellie's scissors in 
use, and have seen them in the practice of others ; and have 
tried Xilian's trephine-perforator. Prof. Thomas's gimlet- 
headed perforator, with a concealed knife working with a 
spring, as well as others. With the forceps, a man may re- 
quire more than one pair ; but he need not own more than 
one perforator. The modifications of Smellie's scissors are 
available in all cases ; the instruments of Kilian and Thomas 
are admirable in cranial presentations, but are not available 
in the delivery of many cases of the head retained in pelvic 
presentations. 

Blot's perforator, on the other hand, is applicable in every 
case in which the perforator can be used. It does not de- 
mand an assistant as Smellie's, and many modifications of his 
instrument do. When the blades are shut, they are super- 
imposed, and no guard is needed except the operator's own 
hand. They are very manageable, readily cleaned, and com- 
mand my entire and hearty preference, and nowadays I use and 
recommend no other to those who wish but one instrument. 



CHOICE OF mSTRIJMENTS. 325 

Still tlie iiistrument of Kilian may facilitate tlie opera- 
tion in cranial presentations for many practitioners, as tliere 
is scarcely any risk of its slipping, and so large a disk of bone 
and scalp is removed therewith that it may possibly facilitate 
the removal of the brain, and injection of water in some cases. 
I do not believe that there is less risk from spicnlse with Kil- 
ian's instrument than with Blot's, when properly used. 

Crotchet. — The best crotchet that I have ever met with is 
Churchill's. It is best made with two points instead of one, 
and these should not be sharp. With this instrument intro- 
duced within the skull, while two fingers of the other hand 
are so held as to make counter-pressure, a powerful traction 
can be exerted. If the hand be so held that the palm will 
receive the force of the instrument if it should slip, no injury 
will be done to the maternal tissues, and I have never known 
any to be done to those of the operator, although one scarred 
hand has been shown to me while this work was going 
through the press. In cases of pelvic presentation this in- 
strument can often be fastened on the occipital bone, when 
the purchase is extremely powerful and not liable to slip. 
With the crotchet delivery can be effected without exposing 
the woman to the additional risk (however slight in compe- 
tent hands) from the application of the blades of craniotomy 
forceps or cephalotribes. The crotchet, in my opinion, is pref- 
erable to any craniotomy forceps which cannot be disarticu- 
lated, and permit the separate introduction of the blades. And 
there are cases in which the cephalotribe cannot be applied 
or used as a tractor until the brain is completely evacuated 
and the diameters lessened, when a more speedy and prompt 
delivery can be effected by the crotchet. If delivery of the 
head with the crotchet threaten to be difficult, the brain 
should be washed out by a stream of water before the trac- 
tions are made. In most cases this is unnecessary, as it 
escapes readily enough during the tractions, if it be well 
broken up before these are made. In bad cases of pelvic 



326 OBSTETEIC OLmiC. 

deformity with a large and well-ossified head, the crotchet is 
not as serviceable as the cephalotribe or Simpson's cranio- 
clast. 

A case of prematnre delivery in a breech presentation is 
given in this work, in which a strong piece of bent wire was 
used for traction. 

Cephalotribe. — I have used this instrument in several 
cases, some of which are published in this volume, and have 
been prepared to use it in others in which (as in the case of 
Mary Foy, No. 100) it was inapphcable for lack of space, un- 
less I had delayed until the brain had been previously fully 
evacuated — a delay which would have been unnecessary, 
while even then the cranioclast would have been preferable, 
as the application was so much simpler. It offers great ad- 
vantages when a very powerful grasp is desired which is not 
liable to slip, and in cases of deformity where it is desirable 
to crush the foetal diameters before delivery. I have always 
used Scanzoni's. Perhaps Braisky's may prove superior. 

I have crushed the heads of a number of still-born chil- 
dren with this instrument for class demonstration, and though 
I have succeeded in fracturing the bi-mastoid diameter with 
it, I have generally failed. "With the ecraseur there is a 
tendency to draw more tissue into the grasp of the instru- 
ment than may be desirable ; with the cephalotribe the oppo- 
site Tesult most generally happens, and while the points of 
the blades may be accurately applied over or beyond the 
mastoid processes, they slip toward the sagittal suture, or 
toward the face in some cases, while they are being forced 
together, and thus avoiding the bi-mastoid diameter, sink 
deeply into the temporal, parietal, or frontal bones. 

In the child delivered in Case ITo. 100, I made some ex- 
periments with Scanzoni's cephalotribe, a few hours after the 
delivery, with the assistance of Dr. W. T. Lusk,'who has 
read an excellent paper on " Cephalotripsy " before the " ISTew 
York Medical Journal Association," published in the Medi- 



CHOICE OF INSTRUMENTS. 327 

cat and Surgical Bejporter of Philadelpliia, for June 8, 
1867. TTe made repeated efforts to fracture tlie bi-mastoid 
diaraeter, and failed, as it appeared on dissection. We suc- 
ceeded in breaking off little pieces of tlie processes, and in 
disarticulating the temporal from the occipital bone. This 
separation diminished the diameter one inch by measure- 
ment with calhpers — an important result — as it thus meas- 
ured only one and a half inches. 

Where the application of the cephalotribe is rendered 
difficult by the narrowness of the pelvis, or the elevation or 
size of the head, it is desirable that the brain should be evac- 
uated by a stream of water injected within the skull, as in 
Case ]N'o, 51. This procedure, in other cases of difficult de- 
livery with the crotchet or cranioclast, may afford great assist- 
ance. An ordinary Davidson's syringe is all that is required. 

Craniotomy forcejps. — ITo craniotomy forceps should be 
pm'chased unless so constructed as to permit the separate in- 
troduction of the blades and their subsequent locking. In my 
opinion Simpson's cranioclast is the best craniotomy forceps 
that has come under my observation, and that with its aid the 
uses of the cephalotribe are very restricted indeed. ITothing 
could have acted better than the cranioclast did in Case 100 
and others recorded in this work. It diminishes the risks 
and difficulties from the introduction of such instruments 
as the cephalotribe, and craniotomy forceps which pass out- 
side of the head, more than one-half. Cases are very rarely 
met with indeed in which it cannot be used. The principle 
is an excellent one. It cannot slip, and its buckle-like model 
is an admirable adaptation ; but like all craniotomy forceps 
it may tear out completely the part which it has grasped, and 
demand successive reapplications. It is in these difficult 
cases that the cephalotribe is so serviceable, since, when that 
is drawn out of the vagina, the whole head comes with it. 
The cranioclast is probably a safer instrument for general use 
than the cephalotribe or crotchet. The screw upon the one 



328 OBSTETRIC CLmiC. 

modified bj Barnes whicli I first used, is so fine that an un- 
necessary amount of time is lost in arranging it. I liave 
caused one to be made by Mr. Ford, of this city, with the 
handles of my forceps, and a very coarse screw, which can 
be ra]3idly adjusted or withdi'awn. 

Meigs^s craniotomy forceps. — In Case !N"o. 103 these 
proved of decided advantage. 

Blunt-hook. — This is often very useful in tractions upon 
the groin, the axilla, or the lower jaw of a dead child. 
For living children it would be well to have curves of differ- 
ent sizes, so that they might be adapted to the groins and 
thighs in difficult pelvic presentations. Examples are given 
of its vai'ious uses, and one peculiar case where it was passed 
through the anus and abdominal wall of a dead child, so as 
to hook it over the pubes. The fillet is preferable in pelvic 
presentations of living children. I have never used the 
double blunt-hook with the obstetric lock. 

Introduction of tJie perforator. — There is but one danger 
— that of glancing off from the head and injuring the maternal 
tissues — -and there is no reason why this should ever happen. 
To prevent this contingency, the operator must keep clearly 
in his mind the axis of the head in the direction which he 
has selected for perforation. If the head be high up or 
movable, it should first be mapped out, and then steadied by 
the hand of an intelligent assistant placed over the mother's 
abdomen. This assistant can distinguish, as Dr. Mead did, 
in Case 100, the passage of the perforator within the cranium. 
After Blot's instrument has been introduced, it should be 
withdrawn until the broadest diameter of the blades is in the 
incision, when they should be carefully opened in two direc- 
tions. After which, keeping them widely separated, I rotate 
them several times in the free opening that has been made, 
thus securing a free and permanent opening through the 
bones and scalp. If the scalp has been well incised, this 



EMBEYOTOMY. 329 

opening is all-snfficient. It is immaterial to me whether the 
perforation be made in a sntm-e or a fontanelle, or through 
the bone. As a rule, I select the depending site. A great 
deal has been said of the risks of lacerating the vagina from 
spiculse of projecting bone in delivery of the perforated head, 
but no cases have come under mj observation, and such an 
accident ought, as it seems to me, to be avoidable. The 
risks from spiculse give the most embarrassment in deliver- 
ing through an undilatable cervix in cases where the cephal- 
otribe could not be used without previous free incision. 

After the perforation has been effected, no instrument 
can be better fitted to break up the brain tissue than Church- 
ill's crotchet, though one blade of the cranioclast answers 
every indication. It generally surprises one, witnessing this 
operation for the first time, to notice the freedom and force 
with which an instrument can be rattled in the cranial 
cavity, but the movement is safe within that bony box. 

It is desirable to break up the brain very thoroughly to 
facilitate the delivery. It may be necessary .to inject the 
cavity of the cranium with water after breaking up the 
brain, and wash out the diffluent mass. 

It is certain that in many cases of perforation the deliv- 
ery is not effected until a great part, and perhaps all, of the 
brain has escaped. If this has only escaped under the trac- 
tions which have compressed the head, and thus squeezed 
out the brain, it is obvious that in certain cases the maternal 
tissues may have been subjected to an unnecessary pressure, 
as the diameter of the head might have been previously les- 
sened by procuring the complete evacuation of its contents. 

Case 140. — Perforation in a case of contracted antero- 
;posterior diameter of Irim ; mother did well. — Dr. Mola, 
House Physician. 

Ann Royal, aged 22, primipara, strong, well-developed, 
healthy-looking girl of medium size, entered the lying-in 
ward at Bellevue at 7 p. m., E"ovember 12, 1863. Os uteri 



330 OBSTETRIC CLINIC. 

noted by Dr. Mola as about as large as a ten-cent piece, and 
not dilatable; pains not strong; bead j)i'esenting ; beart- 
sonnds over left iliac region; uterine souffle also distin- 
guisbable. 

Noveiiiber V6th^ 8 a. m. — Has not slept mucb last nigbt. 
Os still rigid ; dilated to tbe size of a balf-doUar ; membranes 
um'uptured and protruding. Head presenting ; foetal beart 
tbe same. 2.30 p. m.' — Pains a little stronger. Waters bave 
broken, presentation recognized, tbe posterior fontanelle be- 
ing to tbe left acetabulum, and just dipping witbin tbe brim. 
Foetal beart as before. 6 p. m. — Head bas not advanced. 
Os not fully dilated, and somewbat rigid. Pains feeble and 
constant. Tbe examining band is covered witb a greenisb, 
slimy material. Impossible for any one to recognize tbe 
foetal beart. 

I was tben sent for, and arrived at 11.30 p. m., wben tbe 
patient bad been brougbt under cbloroform. I made an ex- 
amination, and found tbe os uteri, presentation, and position 
of tbe bead as noted at 6 p. m. ; wbile, by passing tbe band 
well up, tbe cause of delay could be recognized in an under- 
sized antero-posterior diameter of tbe brim, and tbe left pari- 
etal bone was pressed against and driven in by tbe promon- 
tory at a point between tbe sagittal suture and tbe boss. 
Poetal beart inaudible. Tbe situation left no doubt in my 
mind tbat tbe cbild was dead, and bad probably died from 
injury to tbe cerebral cu'culation; and it seemed tbat for- 
ceps were inadmissible under tbe cnxumstances (especially 
so wben tbe risks of puerperal fever, incident to tbe season, 
were considered), altbougb tbe degree of deformity did not 
forbid tbe trial of a slender pair. Accordingly, Dr. Eowe 
kept up tbe cbloroform, and I introduced Blot's perforator 
near tbe posterior superior angle of tbe rigbt parietal bone, 
and completely broke up tbe brain. Cburcbill's crotcbet be- 
ing tben introduced, tbe bead was gradually and readily 
drawn into tbe world, tbe placenta following almost imme- 
diately. Half an bour afterward Dr. Mola discovered tbat 



OBSTETRIC OPEEATIONS DT DEFORMED PELVES. 331 

tlie uterus, wMcli bad been kept pressed down bj tbe nurse, 
was rather large, and that blood was oozing from tbe vulva. 
Accordingly, be introduced bis band, turned out some clots, 
and gave ergot, and in two bours left tbe patient sleeping 
comfortably. 

Becemler 2, 1S63. — Witb tbe exception of a sligbt feb- 
rile movement on tbe second day after tbe oj^eration, tbere 
bas been notbing wortby of record. Tbe patient will soon 
be able to leave tbe bospital. 

Cbild weigbed eigbt pounds in its mutilated state. 

Case 141. — Contracted outlet ; arrest ; forceps ; jperf oration. 

On Marcb 26tb, 18 — ^ at 9 a. m.,I was requested by Dr. 
Cadmus to see a primipara, aged 30, wbo bad been in tbe 
second stage of labor, witb good pains, at least twenty-two 
bom-s. I found ber witb a tender abdomen, a very dry and 
bot vagina, and a diminisbed outlet, witb an excessively 
rigid perineum. Pulse and expression good. Foetal beart 
distinct to tbe left below tbe umbilicus. Head presenting, 
witb posterior fontanelle to tbe left sacro-iliac syncbondrosis ; 
tbe movement of descent barely completed. 

Tbe condition of tbe motber, tbe disproportion and tbe 
presentation, seemed to me to clearly indicate necessity for 
interference, wbicb was accordingly attempted in tbe pres- 
ence of Dr. Cadmus and Dr. . 

Tbe woman baving been brougbt under cbloroform, I 
desired, of course, to seize tbe bead by tbe bi-parietal diam- 
eter, witb tbe concavity of tbe blades to tbe rigbt, and tbe 
relations of tbe foetal bead to tbe pelvis prevented me from 
seizing it otherwise tban by tbe obbque diameters, wbile tbe 
size of tbe bead demanded tbat tbe pivot should be advanced 
to tbe highest hole, l^ow made every effort which I could to 
rotate or advance tbe bead, first trying to turn tbe occiput 
toward the pubis, then in the hollow of tbe sacrum, or to 
dislodge it in any way from tbe position wbicb it had so long 



332 OBSTETEIC CLINIC. 

occupied with siicli risks to the mother. But mj efforts 
were utterly unavailing, though they were continued until 
there was no alternative for this conviction, and tested alike 
the tractive force of the instrument, and the reliability of the 
pivot to prevent compression. When convinced of the im- 
possibility of delivering the child alive, I pushed back the 
pivot and drew on the head, until the capability of the in- 
strument to act as a compressor was demonstrated by its 
deep traces, but all vdthout success. Determined to try 
them fully, I braced my feet firmly, and pulled myself out 
of breath before they yielded, and when they did, no altera- 
tion of position whatsoever had been effected. It was deemed 
useless to replace them after the trials that had been made, 
and I delivered a large male child with the perforator and 
crotchet. E'o waters of the amnion followed, nor hemor- 
rhage, but a stench came after the child which augured ill 
for the chances of metritis. But, under Dr. Cadmus's care, 
the woman has entirely recovered. 

Case 142. — forceps and jperf orator for deformity of 'brim. 

Mrs. ; menses ceased January 8th, confined on 25th 

of October, 1860, under the care of Dr. Sabine. Diminution 
of antero-posterior diameter of brim from projection forward 
of promontory. Her first labor was terminated with forceps, 
after it had lasted twenty-two hours. Child weighed nearly 
ten pounds, and is now nine years old. The second child 
weighed about ten pounds at birth, is about seven years old, 
and was also delivered with forceps after a labor of eleven 
hours' duration. Her pains were slight during the whole 
day, but became more severe toward night ; at 2 a. m.. Dr. 
S. applied forceps to the head retained at the brim, but with- 
out effect, and sent for me at 3 a.m. I found the head 
above the brim, dipping the arc of one parietal bone into 
the superior strait, but quite movable ; and asked permission 
to make an effort with forceps, which was readily granted, 



EMBEYOTOMT. 333 

and the forceps easily applied, but it was not possible for me 
to succeed anj better. Foetal heart inaudible. I then de- 
livered a large child after opening the head, memorandum 
of weight lost. Mother has done well since (February, 1861), 
and has been confined of a living child. 

The case illustrates the point made regarding the varie- 
ties of labors in the same patient. 

Case 143. — Ai^m in the vagina / head ahove, to the right / 
child dead J perfarator ^ hrow had originally presented. 

Drs. McClelland and Hall sent for me on the 10th of 

April, 1861, to Mrs. , who had been long in labor with 

her second child. The membranes had been ruptured for 
thirty- six hours, and all the waters long since escaped. The 
brow had originally presented, and had become complicated 
by the presence of the left hand and arm in the vagina. I 
found them there, and the fingers did not close on mine. 
Cervix uteri fully dilated, but an unusually rigid circular 
contraction above. Head above the right, partially in the 
iliac fossa and partially overhanging the true pelvis ; brow 
presenting ; foetal heart inaudible ; uterine contractions good 
now, and had been so persistently. Pulse good. No ten- 
derness over uterus. 

The operations to be considered were : 1st, podalic ver- 
sion ; 2d, replacement of arm and cephalic version ; 3d, ditto, 
and delivery by vectis or forceps ; 4:th, replacement of the 
arm and perforation. The last procedure gained my prefer- 
ence in this particular case, and after Dr. Hall had brought 
the woman under the influence of chloroform, I replaced the 
hand and arm in utero ; and then holding the head firmly 
in position with my left hand applied over the right iliac 
fossa, I introduced Blot's perforator, and delivered with the 
crotchet. The uterus contracted well, the placenta came 
away readily, and the contractions were maintained by 
ergot. I believe that the mother recovered well. 



334f OBSTETEIC CLINIC. 

Case 144. — Rupture of uterus ; removal ofjplacenta, and 

"cersion / perforator. 

Dr. Bishop sent for me on the 8th of May, to Mrs. , 



a widow, in labor with her eighth child. The other seven 
had been born living, with the exception of the last, which 
was turned by Dr. Bishop for prolapse of the funis. The 
hnsband had recently died from Bright's disease. 

In this labor, Dr. Bishop had been sent for at 8 a. m., 
and found the os uteri fully dilated, head presenting (post, 
font, to left), foetal heart beating, maternal condition good. 
At half-past 10 he was called away, and left the patient 
under the care of Dr. Sheehan. All continued to go on well 
until about 1 p. m., when she suddenly complained of great 
pain in the abdomen, and a sensation as though something 
had given way. She immediately became very weak, the 
presenting part receded, and no more uterine contractions 
took place. There was no hemorrhage, and no vomiting, 
but nausea, and a disposition to vomit. I saw her with Dr. 
B. at 3 o'clock. Pulse 120, feeble, skin cool, no uterine 
contractions. Abdomen very sensitive to the touch. Head 
presenting ; entirely above the brim in the right iliac fossa, 
and resting on the pubes and right rim of the true pelvis. 
Foetal heart inaudible. On introducing my hand above the 
brim for purposes of exploration, much dark jiuid blood 
escaped. Having introduced my finger into the child's 
mouth, no closure followed, and near by I recognized a loop 
of pulseless funis, not prolapsed. ISTo laceration of the uterus 
could be detected by the finger. While thus engaged, I 
found the placenta on the left side of the uterus, nearly de- 
tached, so I removed it and divided the cord. There was 
no further loss of blood. It may be well to state here that 
nothing had been given to expedite the labor, nor had opera- 
tive measures been resorted to before the collapse. Believing 
that rupture of the uterus had undoubtedly occurred, I pro- 
ceeded, with regret, to the necessary delivery, and, on account 



EMBETOTOMY. 335 

of lier weak state, we were obliged to decline tlie ausesthetic 
for wliich she begged piteoiislj imtil after the operation was 
commenced, when she no longer embarrassed us by a single 
word. We agreed that the perforator should be tried first, 
and if that failed, then podalic version. Dr. Bishop steadied 
the head in the right iliac fossa, and I introduced mj hand 
wholly within the vagina as a guide to the perforator ; but 
the mobility of the head and the pain from the necessary 
pressure, caused us to decide on version, and I brought the 
feet and arms readily into the world; but the chin became 
fixed over the left linea ilio-pectinea, the sagittal suture run- 
ning transversely. The child was a male, of large size; 
there was no room whatever behind the left acetabulum to 
push back and flex the chin, and I found it impossible to de- 
liver manually. Dr. Bishop then faithfully made every effort 
to flex the chin without success, when I introduced the per- 
forator into the highest part which I could reach, viz., in the 
posterior part of the neck on the right side, three-quarters 
of an inch below the tip of the mastoid process, and working 
the instrument through the sheath of tissues, penetrated the 
occipital bone. The crotchet, however, failed to advance 
the head, and accordingly I passed a blunt-hook in front of 
the left sacro-iliac synchondrosis, and turning it in the direc- 
tion which seemed best adapted to enter the mouth, succeeded 
in fastening it firmly ; when having fractured and brought 
down the lower jaw without advancing the head, I drew 
firmly and simultaneously with the crotchet and blunt-hook 
until the 'brain began to escape freely^ and the head came 
into the world. The uterus contracted immediately and 
firmly, and careful exploration by two fingers within, and 
thorough exploration of the posterior uterine wall through 
the relaxed abdominal walls, failed to furnish me with any 
evidences of laceration. The patient pronounced herself 
much better, and we gave her every encouragement. Symp- 
toms of peritonitis soon set in, however, which were actively 
treated in the usual way, but without effect. The vomiting 



336 OBSTETRIC CLINIC. 

became of a coffee-ground color, no locliia wliatever flowed, 
and she died on the 12th. 'No autopsy permitted. 

In this case I do not think that the cranium could have 
been injected satisfactorily. 

Case 145. — Piierjperal edamjpsia in the sixth or seventh 
month of gestation / labor brought on y venesection / douche / 
purgatives / delivery with crotchet made of strong wire. 

At 1 A. M., December 6, 1856, my friend, Dr. H. S. 
Hewit, requested me to meet him in consultation, and 
brought me to the bedside of a plethoric, strongly-built pri- 
mipara, aged 34. She was comatose, and breathing sterto- 
rously ; her face, feet, and ankles cedematous ; the blood 
trickling from a lacerated tongue. She had not exhibited 
one ray of consciousness from 3 o'clock in the afternoon ; 
and from that time, convulsions had succeeded each other 
with about half-hour intervals. No foetal heart was audible, 
and vaginal examination disclosed a dry and hot vagina ; a 
long, hard, and undilated cervix, with the uterus at about 
the sixth or seventh month of gestation. I could, with much 
force, thrust my finger far enough to be sure that I could de- 
tect the membranes, with some portion of the foetus present- 
ing — ^perhaps, the head. There was scarcely any urine in the 
bladder, and that, when drawn off with the catheter, and 
tested with nitric acid, became completely coagulated. 

Dr. Hewit had seen her for the first time, at about 9 
P.M., and with Dr. Stewart had withdrawn nearly one quart 
of blood from her arm, which did not coagulate well ; hyd. 
chlor. mit. 3 j on back of tongue. On inquuy, we learned 
that she was reserved in disposition, and much depressed in 
spirits of late, from domestic trouble ; still, our informants 
could now remember that she had been obliged to lay aside 
her rings of late, as they had become inconveniently tight — 
that her face had been noticeably swollen, and that, on the 
morning of the 5th, she had suffered greatly from pain in the 
head ; the convulsion came suddenly, without warning to them. 

We noticed, in her motions and her convulsions, that the 



EMBETOTOMT. 337 



left arm and leg did not stir. Some fom- hom'S liaving 
elapsed since the blood-letting, witliont effect on the os, 
abont a gallon of warm water was played against the nterine 
orifice. "Within an hom-'s time, the vagina became percep- 
tibly relaxed, and the os perceptibly softened. In a short 
time longer, my finger conld reach the membranes with ease ; 
when I punctnred the membranes with the stilette, and recog- 
nized a breech presentation. In little more than an honr 
longer, two fingers conld. pass readily through the cervix. 
There was not sufficient space left for a blunt-hook, but it 
occm-red to me, that a strong wire, bent in the form of 
a hook, might be of service. A piece was procured, and 
bent with strong forceps. The first effort to introduce this 
failing fi'om the size of the curve, this was now made smaller, 
and fastening it around the leg of the child, I was gratified 
to find that it sank into the flesh, and would allow strong 
traction without slipping ; with this, and one finger, the pel- 
vic extremity was withdrawn, and then the remainder of the 
body extracted. The placenta was taken away entire. 
The womb contracted nicely, and the woman lost no blood 
from the vagina. During the removal of the child, the pa- 
tient had one convulsion, in which she raised the left arm ; 
but, while injecting the water, and while delivering her, she 
was placed in the ordinary position for the forceps, with her 
feet confided, separately, to women — and at neither time did 
she move the left leg, though she used the other with con- 
siderable force. ISTo return to consciousness took place; 
blisters were applied to temples and the nape of the neck, 
but at about 10 a. m. she died in a convulsion, after twenty 
hours of unconsciousness. 'No post-mortem allowed. 

Case 146. — Remarkdble example of fatty degeneration of 
foetus and placenta at term / peculiar use of hlunt-hoolc. — 
Bellevue Hospital — Drs. Ersldne Mason and Rives, House 
Physicians. 

Eosa Buckley, aged 31 ; twice married, and now a widow 

22 



338 OBSTETRIC CLINIC. 

for the second time ; commenced her fourteenth labor on the 
26th of February, 1861, at 8 a. m., and was delivered on the 
2Tth, at 5 p. M., of a still-born, pntrid boy, weighing nine 
ponnds. I foimd her in the Ijing-in ward, in labor, at 4 p. m. 
on the 2Tth, and was struck with the enormous size of her 
abdomen, which I regret not haying measured. The general 
expression of the patient was that of albuminuria, though 
careful examinations by Dr. Mason failed to detect any 
thing abnormal. The breech was presenting ; no foetal heart 
or uterine souffle. At this time the membranes ruptured 
during a strong pain, when an immense quantity of offensive 
bloody water was discharged, leaving the left half of the 
uterine tumor still distended, as though possibly by the 
unruptured amniotic bag of a twin. On both sides of the 
uterus abdominal palpitation recognized the outlines of hard 
bodies, those of a foetus distinct to the right. The breech 
presenting evidently belonged to a dead child, as the sphinc- 
ter ani did not contract around the finger, and the skin peeled 
off. Having decided to proceed to the delivery, I brought 
down the legs, with the toes anteriorly. The epidermis 
peeled off readily, but the discoloration frequently seen was 
not present, the skin, however, presenting spots like those of 
simple purpui'a. Having wrapped a towel carefully around 
the right leg, which was the one destined to come anteriorly, 
the bones snapped at once, on the most moderate traction. 
Continuing these tractions with increased care, I was sur- 
prised to find the leg separate entu'ely at the point of fracture. 
The skin divided as though cut with a sharp knife, and was 
cleanly dissected from the adipose layer. The bones were 
denuded and dry-looking, like boiled mutton-bones. In spite 
of my care, the greatest traction available reproduced a like 
result with both the other leg and the thigh. I then, with 
great ease, passed a blunt-hook within the flaccid anus, and 
through the abdominal wall, so as to hook it over the pubes, 
and made cautious tractions in the proper axis, and with 
good effect, until it fractured the pubes, and tore partially 



EMBRYOTOMY. 339 

through the foetal tissues. This manoeuvre, however, had 
enabled me to get hold of the crests of the ilia, and subse- 
quently to draw down the trunk ; but I heard the bones of 
the neck snap, and was obliged to stop. Managed to get the 
arms down without injury, and found that the cervical ver- 
terbrse had separated widely, though the skin was nnbroken. 
"With the blunt-hook in the mouth I terminated the delivery, 
and the body was followed by a gush of offensive bloody 
waters which I have never seen equalled in amomit. The 
placenta came away readily, and was found to weigh 5 lbs. 
2 oz. It was entirely fatty — more completely so than any 
which has ever come under my observation — and the foetal 
tissues, examined by Dr. Jacobi under the microscope, were 
found to have undergone fatty degeneration. 

The foetus and placenta were shown to the Pathological 
Society. 

This patient (who recovered perfectly) informed me that 
I had recommended her to come into Bellevue for the induc- 
tion of premature labor, in consequence of a previous labor 
in the hospital having been complicated with fatty degenera- 
tion of the placenta. That labor occurred in March, 1858, 
and the name is recorded as Eosa Bennett, number of preg- 
nancy twelfth. The case is distinct in my recollection. 

Rosa has been twice married. By the first husband she 
had seven children, all born living, and three still alive ; the 
other four died between the ages of one and ten. By the 
second husband seven children, all of whom are dead, and 
^ve premature and still-born. Two were not premature, and 
lived an hour or two after birth. The second husband died 
from phthisis. Cause of death of the first, not known. 

Case 147. — History of one of Bosa's previous labors, — 
Bellevue Hospital — F. A. Burrall, House Surgeon. 

In labor from March 3, 1858, to 7.17 p. m. Still-born 
male child, weighing 3^ lbs. ^ 



340 OBSTETEIC CLINIC. 

Left heel presented just over os uteri, wliicL. was higL. 
up and directed forward. Drs. Fordjce Barker and Elliot 
called, and about lialf an hour after ruptui^e of the mem- 
branes the left foot appeared just outside of the vulva, heel 
posteriorly. A movement of rotation then took place, and 
the posterior plane of the foetus came in front. Considerable 
delay after the breech was delivered. Child dead. Cuticle 
desquamating. Upper part of body delivered by Dr. Barker 
after cutting the cord. The foetus seemed to have been dead 
a long time, and was almost pulpy. The uterus remained 
very large, and simulated the appearance of a twin preg- 
nancy. This depended on a large placenta filled with effused 
blood. After its removal by Dr. Barker it was found to 
weigh two and three-quarters pounds. Previous to her en- 
trance into the lying-in ward, she mistook a discharge of 
blood for the waters. Uterus contracted well. 

The following case illustrates a condition depicted in 
Cruveilhier's plates: 

Case 148. — Twins i one living — one jyictrid ; death * 
fatty degeneration of ^placenta of the latter. 

Mary Eeed ; single ; aged 26 ; first pregnancy. In labor 
from February 19th, 6 p. m., 1861, to February 20th, 8 a. m., 
in Bellevue Hospital. Drs. Mason and Eives. 

First child a boy ; L. O. A. ; living ; weight, six pounds. 
Second, dead and putrid ; weight, three pounds ; foothng. 
One placenta with two sets of cords and two sets of mem- 
branes. Line of demarcation distinct. One portion small 
and very fatty, both to the eye and under the microscope. 
The other one-thii-d larger and healthy. Placenta shown to 
the Pathological Society at the same time with the placenta 
in the case last recorded. 



CHAPTEE XII. 



VEESIOIS'. 

General considerations. — Case: ChUd dead; uterus distended by gases; ver- 
sion. — How to appreciate the position of the child by examining its 
hand. — Case: Yersion for transverse presentation of second twin. — 
Spontaneous expulsion. — Case: Spontaneous expulsion by cephalic ver- 
sion of the second twin presenting originally \\x a transverse position. 
— ^Dangers of version. — ^Version in deformed pelves. — Case: Twins; con- 
tracted conjugate ; vesico-vaginal fistula after the first labor, cured by Dr. 
Emmet ; perforation of both twins in the second labor, the first pre- 
senting the breech and the second the head. — German experience in version 
as an elective operation in deformed pelves. — Case : Deformed pelvis ; 
dwarf; forceps; version. — Case: Deformity of the conjugate; forceps; 
version; perforation. — Case: Contraction of conjugate; forceps ; version ; 
perforation. — Case: Transverse presentation ; difl&cult version ; prolapse of 
funis. — Case : Presentation of nape of neck and shoulder in a contracted 
pelvis; version; blunt-hook. — Case: Oblique cranial presentation from left 
uterine obliquity ; forceps ; perforator. — Fracture of limbs in version, or in 
original pelvic presentation, — Case: Version for transverse presentation; 
fracture of arms; forceps. — Case: Forceps in occipito-posterior presenta- 
tion ; fracture of arm. 

General considerations. — Yersion can be performed in 
several ways : I. Podalic ; II. Cephalic. 

I. a. By drawing down one or both, of the pelvic extremi- 
ties of the child, with the hand introduced for that pm^pose 
in utero. 

h. By conjoined manipulation. The fingers introduced 
within the cervix, pressing up the untoward presenting part, 
and prepared to act at the proper moment, while the uterus 



842 OBSTETEIC CLINIC. 

is skilfully manipulated meanwhile tlirougli the abdominal 
wall, so as to facilitate tlie grasp of one or both of the infe- 
rior extremities of the foetus. 

c. Bj external manipulation alone. Coaxing away the 
obnoxious presenting part, and bringing the foetal head or 
pelvis to the superior strait. I have more than once turned 
the second twin in this way with a facility that has aston- 
ished me. 

These manoeuvres may be facilitated by the fillet, the 
blunt-hook, or the craniotomy forceps. 

II. By bringing the foetal head to the pelvic brim, by 
any of the methods employed in podalic version. 

These manoeuvres may be aided in certain cases by the 
vectis, the forceps, the perforator, crotchet, or cranio- 
clast. 

In every variety of version the operation is remarkably 
facilitated by the previous administration of an anaesthetic ; 
and it may be desirable that the patient should be brought 
so profoundly imder its influence as to diminish, if possible, 
the uterine contractions, as well as to abolish voluntary 
efforts. 

There are many cases of cephalic presentation in which 
version is an elective operation, viz., whenever the head can 
be moved above the brim out of the way of the descending 
trunk of the child, and when immediate delivery is demanded 
on account of danger to the life of the mother or the child. 
It is also elective in cases of deformity of the pelvis which 
wiU allow the incompressible diameter (bi-mastoid) of the 
head to pass. 

In both of these contingencies the election is determined 
by various motives. Yersion is an easier operation, as a rule, 
and for most practitioners, than the ajDplication of forceps 
within and above the brim; and this consideration justly 
decides the question in certain cases. One practitioner may 
be led by his experience to think that he personally can de- 
liver more readily by version than by forceps in a given case. 



VEESIOlsT. 34:3 

and therefore slionld clioose the former operation. In the 
practice of one man similar cases may have resulted more for- 
tunately when delivered by version than by forceps, or vice 
versa ; and hence, in the words of the proverb, he prefers the 
bridge vrhich has carried him safely over. Finally, the con- 
trolling influence of an eminent teacher has its weight with 
his pupils and followers. 

It is, therefore, not surprising that the operation should 
be considered from many points of view ; that it should be 
overestimated and undervalued ; that it should be unjustly 
neglected and injudiciously used in inappropriate cases. 
Dr. Figg, in Great Britain, seems to think that the law of 
Katm-e which gives us so vast a percentage of cephalic pre- 
sentations in the birth of living children, can be advanta- 
geously changed for version by the feet in his practice. Gar- 
dien alludes to a similar enthusiast for the operation in his 
times. 

In my own experience version has been very often neces- 
sary, and very often elective. In many cases the simile of 
Burns has been applicable, and version has been attended 
with no more difficulty than if the foetus had been turned in 
a bucket of water. In other cases all my efforts and those 
of my friends have been unavailing, and a mutilated child 
has had to be withdrawn. I can personally appreciate the 
feelings of an old obstetric author (though without having 
suffered to the same extent^ who recounts that after a diffi- 
cult case of version he thought that he would die, and had 
to be rubbed before a fire. 

As a rule the delivery of the second twin by version is 
the simplest of these operations, and the sooner that delivery 
is effected by this method the better when the second child 
is placed transversely, and there be not some special contra- 
indication. 

In the following singular case version was rendered re- 
markably easy by a very strange state of things : 



344 OBSTETEIC CLDaC. 

Case 149. — Child dead ; uterus distended with gases; 
mrsioii. 

Dming my residence in the Lying-in Asylum I was sent 
for on one occasion by Dr. Pulling to see Mary Kelley, aged 
30 ; fourtli confinement, in tlie last stages of exhaustion from 
protracted labor, wbicli bad lasted forty-nine hours. She 
had been deserted by the practitioner who had undertaken 
the case, and then Dr. Pulling was summoned. My friend 
Dr. C. E. Isaacs happened to be with me, and accompanied 
me. We found the patient with all the symptoms attending 
extreme exhaustion — child dead, with head presenting and 
floating above the linea ilio-pectinea. The uterine tumor 
was markedly tympanitic and all the waters had escaped ; 
pelvis ample. The uterine walls were so distended that the 
child floated in these gases, as though in the liquor amnii. 

Under these peculiar circumstances we decided to perform 
version, as it seemed to me that this could be performed with 
great ease, and no delay. My expectations were verified. 
Do not think that I ever turned more readily, not even with 
the second twin. While disengaging the liead, inhaled a 
quantity of such foetid gases escaping from the uterus, that 
I was obliged to give up the management of the placenta, 
and retire gasping and retching to a neighboring window. 
The woman died within the twenty-four houi^. ]^o post- 
mortem obtained. The child was not emphysematous, nor 
very putrid. 

How to ajppreciate the position of the child hy examining 
its hand. — It may sometimes assist the diagnosis of the exact 
position of the child to bring down the arm and examine 
the hand. "When the palm of the child's hand is placed 
against the palm of the physician's hand, so that the fingers 
of one point toward the wrist of the other, the right hand of 
the child and the right of the physician have their thumbs 
in apposition, and so with the left hands, but the right hand 
of the one and the left hand of the other do not so correspond. 



YEKSION. 345 

In this way it is easy to tell at once which foetal hand is pre- 
senting. 

If the radius and nlna of the child's hand be placed in the 
same plane, and the arm be not twisted — facts which are sus- 
ceptible of prompt appreciation — the direction of the child's 
palm corresponds with that of its abdomen, and the thumb 
points to the direction of the child's head. 

The expert should, however, very rarely indeed be called 
on to determine the position by drawing down the hand. 
Conjoined manipulation will often suffice to determine the 
position, or a Httle reflection will enable one to work out the 
problem when the child's hand can just be reached at the 
brim, or in utero, by the examining finger. In version by 
external or conjoined manipulation, or cephalic version, this 
manoeuvre, as a law, should not be employed. 

Case 150. — Versionfor transverse jpresentation of second twin. 

Sarah Burns, aged 31, fourth confinement, October 4, 
1852. 1. Yertex — ^born alive. 2. Left elbow — still-born — 
twenty-fom- hours in labor. Placenta weighed three pounds. 
Lying-in Asylum. 

October 3d, 4 p. m., os uteri fully dilated. Pains insuffi- 
cient. Foetal heart audible. Disposed to sleep. Allowed 
to pass a quiet night. In the morning foetal heart undi- 
minished in force and frequency, and mother's condition 
good, gave tr. of ergot, which quickly expelled the first 
child. The second presented the left elbow — no foetal heart 
audible, but so loud a uterine souffie as to make the negative 
result unsatisfactory. Sent for Drs. Cheesman and T. F. 
Cock. Having waited an hour for them, I proceeded to turn 
in the presence of Drs. George A. Peters and T. M. Chees- 
man, the woman having previously taken some stimulus, 
and been brought fully under the influence of chloroform. 
Having first brought the hand externally to the vulva and 
satisfied myself regarding the position of the foetus in utero, 
I introduced my right hand, and delivered. Child unin- 



346 OBSTETRIC CLINIC. 

jiired, dead, witliont tlie least trace of pnlsation of its heart. 
Patient did well subsequently, requiring only vaginal deodor- 
izing injections. 

Spontaneous expulsion. — We should not expect that the 
unaided efforts of Nature will deliver in cases of transverse 
presentation of the foetus. These successful contingencies 
are too rare, and demand a fortunate combination of condi- 
tions both on the part of the child and of the mother, on 
which we have no right to rely, and for which we should not 
sacrifice valuable time. The cases in which this result may 
most frequently happen, are those where an ample pelvis and 
powerful expulsive pains coexist with a very small or pre- 
mature child, or with the second of twins. 

I have seen two cases of this mechanism in premature 
cases which confii-med the description given by Douglass, of 
Dublin, and the following one in the E'ew York Lying-in 
Asylum, when resident physician there, in which cephalic 
version was spontaneously performed. 

Case 151. — Spontaneous expulsion hy cephalie version of 
the second twin^ presenting originally in a transverse posi- 
tion, 

A woman fell in labor in the asylum, and a breech pre- 
sentation was recognized. The pains were very powerful, 
and the child was forcibly expelled during one of them, 
neither the arms nor head requiring the slightest attention. 
It weighed eight pounds. Finding then that the arm of a 
second child was presenting at the brim, and the head in the 
left iliac fossa, I sent at once, according to the rule, for Dr. 
Beadle, one of the physicians, who lived near by and came 
promptly. But before he arrived, in one of these powerful 
pains, the head of the child was driven into the pelvis, and 
the elbow turned down so as to pass with it into the world. 
The whole child was driven out of the vagina without as- 
sistance. It weighed four and a half pounds. Both living. 
Mother did welL 



VEESioN". 347 

Dangers of version. — It is imdeniable that version is at- 
tended witli great danger to the mother and to the child. 
Statistics show this indispntablj. The danger to the mother 
increases in dii'ect ratio to the time which has elapsed since 
the waters were evacuated. It is probably greatest in lying- 
in hospitals, and especially during those times when puer- 
peral inflammations and fevers are most rife. Its dangers 
increase in direct ratio to the amount of manipulation within 
the uterus, and to the amount of pressure, and bruising of 
maternal tissues involved. Hence those methods of oper- 
ating should be preferred, when practicable, which demand 
the least intra-uterine manipulation. 

Although version by external manipulation is no novelty 
in obstetric literature, it has been accepted by the mass of 
the profession too recently to enable us to say how far it may 
hereafter be shown to have diminished the risks of the oper- 
ation to the mother. It is not probable that those to the 
child will be materially altered thereby. These are un- 
doubtedly very great indeed, even though statistics be care- 
fully weeded of cases where there was reason to suspect that 
the foetus was dead before the operation, and of those cases 
where the operation may be considered as having been un- 
skilfully performed. 

The late Dr. E,uss Brownell informed me, that while 
serving as acting assistant-surgeon in Tennessee, an old negro 
woman, long engaged in midwifery practice, described the 
steps of version by external manipulation quite accurately, 
and said that she had known and practised it always. Doubt- 
less the rude and imperfectly-described manipulations in 
Eaynalde and older authors must have been occasionally 
successful in changing the presentation, and may have been 
practised better than they are described. 

I always regret to meet a pelvic presentation in my prac- 
tice, for fear that the child may not be born alive ; and I 
firmly believe in having forceps at hand in these cases, that 
no contingency may arise which may not be provided for. 



34:8 OBSTETEIC CLunc. 

Meigs lias triilj and forcibly said of these cases, tliat " the 
child may die while the messenger is putting on his boots." 

While accepting, therefore, all these risks, which are in- 
evitable in the original pelvic presentation, and in cases 
where version is an operation of necessity, they come np 
again in those cases where the operation is elective. It will 
be a happy day for those who mnst take these responsibili- 
ties, when the gradually accumulating masses of statistics 
have been analyzed by an " achromatic brain," and the 
laws so formulated as greatly to relieve individual responsi- 
bility. 

Version in deformed pelves as an elective operation. — 
In no class of cases, perhaps, may these remarks be more 
applicable than in those where there is moderate deformity 
of the pelvis with a living child, and the choice has to be 
made between forceps and version. 

In one case I have delivered with version after I had 
failed with forceps ; and while I have delivered successfully 
and satisfactorily by version in some cases — in others where 
I have tried version after failing with forceps, it has not been 
more successful. Examples of these results are scattered 
through the book, and some are subjoined. 

Every now and then we meet with recorded cases of ver- 
sion in deformed pelves where the results are so satisfactory 
that one feels as though they should establish the law for our 
interference. But, alas! few men are willing to print a 
frank statement of all their failures. Certainly, for my own 
part, despite my admiration for Sir James Simpson's theory 
and argument, my own preferences are for forceps as an elec- 
tive operation, though time and further observation may 
change my views. Still, my experience thus far, and the 
opportunities which I have enjoyed for witnessing the oper- 
ations of others, strengthen my opinion. 

In a conjugate of three inches and upward, with a living 
child and a head presentation, my first choice would be for 



YEESioiir. 349 

forceps. Between two and a half and three, if the child were 
living, I should perform version. 

Case 152. — Twins; contracted conjugate j vesico-vaginal 
fistula after first labor cured hy Dr. Emmet • jperforation 
of loth twins in this labor, the first presenting the breech and 
the second the head. — Dr. J. C. Stone, House Physician, 

Sarah Cornell; English; married; second pregnancy. Last 
menstrual period August 10, 1862. Labor commenced May 
Tth, 12 A. M., and terminated May 8th, 4 p. m. Two male 
children, TJ lbs. each. 

Patient is medium-sized, has always been healthy till 
the first confinement in March 8, 1860. She was then in 
labor for five days, the second stage lasting three days, child 
born dead, weighing 10 J- lbs., and was taken from her with 
great difficulty, though she is not aware that instruments 
were employed. For three months following she suffered ex- 
ceedingly from inflammation and sloughing of the parts, and 
subsequently placed herself under the care of Dr. T. A. Em- 
met, at the Women's Hospital, where she remained until 
August, 1861. The vagina was occluded by fibrous bands. 
These were all removed successfully by Dr. Emmet, though 
the operation induced metritis, and placed her life in jeop- 
ardy. She remained at home suffering from vesico-vaginal 
fistula, until March, 1862, when she returned to Dr. Emmet, 
and continued with him until the 16th of July, when she 
left, entirely well. About one month after returning home 
she became pregnant, and a week previous to her confine- 
ment, dreading the labor, came to Bellevue. She was ad- 
mitted April 30th. General health good. Marked oedema 
of lower extremities. Slight dulness anteriorly and poste- 
riorly over left upper lobe, but no marked auscultatory 
signs. Distinct aortic regurgitant murmur. Urine examined 
several times, detecting a slight shade of albumen ; abundance 
of pus, but no casts. Dr. Barker examined her on the 8th 



850 OBSTETEIO CLINIC. 

of May, and found tlie vagina partially occluded by several 
fibrous bands at its upper portion. The same night the 
waters broke. During tlie whole of the Yth, till 6 A. m., 
May 8th, she had sharp labor-pains at intervals of thirty 
minutes. The head then descended into the lower strait, 
and although the pains were strong and frequent, no per- 
ceptible advance was made until 9 a. m. Two foetal hearts 
were distinctly audible through the night, one just above the 
pubes, and the other just above the umbilicus-. Dr. Barker 
had also diagnosticated a breech presentation on the previous 
evening. At 11 a. m. of the 8th the breech passed the vulva, 
and Dr. Taylor, being present, proceeded to deliver at once, 
on account of hemorrhage. The breech and shoulders of- 
fered but little resistance, but it was found impossible to de- 
liver the head without perforation. The whole operation 
occupied an hour. The placenta came away a few minutes 
afterward. The hemorrhage then ceased. 'No ether nor 
chloroform administered on account of the cardiac murmm\ 
At the close of the operation the pulse was 88, soft and firm. 

The head of the other child could be easily felt, resting 
on the symphisis pubis, and no advance having been made 
at 4 p. M., Drs. Barker and Elliot having carefully examined 
the parts, and finding that the conjugate diameter was but 
2| inches, and detecting no foetal heart, decided to deliver 
by perforation, which was done by Dr. Elliot. 

Dming this last operation, however, the patient was 
brought fully under the influence of chloroform. Shght ten- 
dency to hemorrhage, and the binder not applied for three 
hours, until contraction was brought about. 

The patient recovered without any other adverse symp- 
toms than the reestablishment of her vesico- vaginal fistula. 
For this she again sought Dr. Emmet's advice. He found 
that the old cicatrices had again contracted, and that the 
old fistula had again opened. He* cured the fistula in one 
operation, but as pregnancy was not desirable, took no 
measures to insure permanent dilatation of the vagina. 



VEESION". 351 

Bemarks, — This case points out the difficulties to be met 
Tvitli in degrees of deformity in wliicli forceps are considered 
inapplicable, and the alternatiye of version wonld commend 
itself so heartily to many excellent authorities. And yet this 
original pelvic presentation in a moderate-sized child had to 
be tei-minated, after all, by the peforator. I regret not to 
have preserved memoranda of more cases of this kind which 
I have witnessed in the practice of others, where, in original 
and converted pelvic presentations, the final delivery had to 
be brought about after perforation of a dead child. 

German experience in version as an elective ojperation in 
contracted jpelvis. — As a further contribution to the litera- 
ture of this subject, Dr. William T. Lusk has kindly pre- 
pared the following analysis at my request : 

" Scanzoni has reported three cases of version in pelves 
measuring in the conjugate diameter respectively 3 J, 3|^, 
and 3| inches. All the children were born living. Martin 
reports one case of version in an oblique ovate pelvis in 
which the child was dehvered alive. Eosshirt reports one 
case where the child was delivered dead. Birnbaum reports 
^^Q cases in all of which the children were delivered dead.. 
Poppel reports a case of version where premature labor was 
induced in the thirty-fifth week. The child died after ten 
days. In a second pregnancy of the same woman version 
was employed, but the child was delivered dead. 

"Thus in twelve cases there were seven deaths. The 
^Q successful cases were in pelves with moderate deformity, 
unless we except Scanzoni's case of 3 J inches. In Scanzoni's 
case, where the conjugate measured 3f inches, the woman 
had previously borne four children naturally. In four of 
Birnbaum's cases the weight of the children varied between 
seven and eight pounds. The fifth case was complicated with 
prolapsed funis. In Martin's case the difficulty in delivery 
arose from the broadest diameter of the head having been 
engaged in the narrowest diameter of the pelvis. This was 
readily obviated by version. 



352 OBSTETEIC CLIN-IC. 

" lu the Dresden Hospital Ee])orts, furnished by Grenser, 
between 1861-1865 inclusive, sixty-three cases of deformed 
pelves measui'ing from 2f to 3 J- inches in the conjugate are 
reported. Of these, twenty cases were delivered naturally 
with nineteen children born living, and only one child born 
dead. There were three children born alive when the pelvis 
measured 2f inches. In one of these, where the labor lasted 
twenty-two hom*s, a living child was delivered weighing six 
and a half pounds. There were likewise twenty-seven for- 
ceps cases. In these fifteen childi-en were delivered dead. 
One case of version, preceded by prematm^e labor, terminated 
fatally for the child. 

" In the retm^ns from the Institute for Mid wives in Co- 
logne, 1860-1863, Fr. Birnbaum, Director, one hundred and 
fourteen cases of contracted pelves are reported. Of these 
there were sixty-one where the delivery was natural. In 
forty-three instances operative procedures were resorted to. 
The "Q-ve cases of version, terminating fatally, I have already 
given. Two cases of pelvic presentations (extraction em- 
ployed) were resuscitated. Out of twenty-one forceps cases 
there were seven deaths. 

" In Munich two cases of version following prematm-e 
labor, with death of child, have been reported. 

" Thus in one hundred and seventy-nine cases of vari- 
ously contracted pelves there were eighty-one instances of 
natural delivery, and in twenty of these cases where the 
result was exactly given, there were nineteen children born 
living. In ninety-eight cases art was employed. In forty- 
eight forceps cases there were twenty-two deaths. In eight 
cases of version all the children were delivered dead. In two 
breech cases, with extraction, the children were resuscitated. 

" From these figures it appears that so far as regards the 
safety of the child, the best results are obtained when the 
head is gradually moulded by the uterme forces. Where 
the latter are insufficient the superiority of forceps to version 
is amply vindicated. 



VERSION. 353 

" To test the question of forceps versus version, Hennig 
carefully examined the reports for a series of years of fifty 
German lying-in institutions, which presented a total of 
37,970 cases, and reported the results to the Obstetrical So- 
ciety of Leipsic in 1863. He found in the few cases given 
where, in a contracted pelvis, version and extraction were 
both performed, all the children died either during the op- 
eration or shortly after. In pelvic births in contracted pelves, 
vrithout intervention of art, all the children died. Several 
directors of clinics were so fortunate as to have a large num- 
ber of forceps deliveries without losing a single child. Even 
where some degree of pelvic deformity existed, there was a 
loss of only one in twenty-six cases. Head presentations, 
where disproportion between head and pelvis existed, gave as 
a whole, including several forceps extractions, thirty per cent, 
of deaths. In perfectly well-formed pelves the mortality of 
healthy children at term amounted in breech presentations 
to 2.3 per cent. ; in cephalic presentations, to 1.2 per cent. 

'* These figures do not support Prof. Simpson's idea that 
when the child presents preternaturally in a morbid con- 
tracted pelvis, the labor is easier and safer to the mother and 
infant than when the head jDresents. 

" As a further test, Hennig wrote to the directors of most 
of the lying-in hospitals of Germany, asking for examples 
occurring in their practice bearing npon this subject. In 
answer he received reports of eleven cases, with the following 
results: Seven mothers and four children survived; two 
mothers and five children died. In two cases the result was 
not stated. The two mothers died previous to delivery, one 
of them surely from attempts at delivery previous to version. 
In neither case was death attributable to version. Three 
children were born dead, one (hydrocephalic) dying, and one 
died during delivery. Adding McClintock's cases to the 
eleven reported, there would be exactly the same number of 
children saved as of those that perished, viz., thirteen of 
each. Of the thirteen born dead, nine are reported as hav- 
23 



354: OBSTETEIC CLINIC. 

ing been alive previous to delivery. In these cases tlie con- 
jugate measured from 3 to 3f inches. Out of a hundred 
similar cases occm-ring in the Poliklink in Halle and Leip- 
sic, in which forceps were nsed, fom' died — a fact which 
does not speak well for version employed as a prophylactic 
measure in interest of the child. Excluding the Irish cases, 
however, and assimaing that in only one of the German cases 
death was directly due to the operation, there would still be 
nine per cent, of deaths due to version. Going still further, 
and placing all the cases of vertex deliveries in contracted 
pelves, whether terminated by art or not, upon one side, 
and on the other the results of version in moderately con- 
tracted pelves, excluding all cases in which the child died 
or showed signs of feebleness previous to the operation, we 
wonld have thirty per cent, of deaths for the &st, and thirty- 
six per cent, for the second, leaving thus still a small margin 
in favor of head presentation, even after avoiding every 
imaginable somxe of error." 

Case 153. — Deforoiied ;pelvis ; dvxirf ; forcejps ; version; 
fever. 

Ellen Bumheimer ; Bellevne ; aged 29 ; first labor ; dm-a- 
tion of labor, thii'ty-fom^ hom'S. Female child ; still-born ; 
weight, seven pounds; L. O. A. Mother died seventeen 
hours afterward, from puerperal fever, then prevalent in 
Bellevue Hospital. 

Forceps failing to draw the head through the contracted 
brim, I dehvered by version. Chloroform. 

Case 154. — Deformity of antero-XjOsUrior diameter of 
'brim / forceps / version / perforation. 

Mary O'Connell, aged 33 ; third pregnancy. Bellevue. 
Drs. Andrews and Maury. Labor commenced May 15th, 
10 p. M. ; L. O. A. ; terminated May 16th, 11.15 p. m. Child 
still-born ; girl ; weight, nine pounds. 



VERSION. 355 

Patient short stature, apparently well formed ; married 
ten years ; first child delivered naturally, and living, though 
somewhat before the full time. Four years later delivered 
after a tedious labor, of a still-born child. Mary was one of 
those unsatisfactory patients from whom one can with diffi- 
culty learn any thing, and when the answer is obtained one 
has to suspect that almost as much as the previous uncer- 
tainty. However, at 7 p. m., 16th, Dr. Andrews on carefully 
examining the patient appreciated the presentation and posi- 
tion, and rupture of membranes, and detected a diminution of 
the antero-posterior diameter of brim to somewhat less than 
three inches. He sent for me. I agreed with him entirely, 
believed it impossible for the child to pass, and anticipated 
very hard work. Sent for my colleague. Dr. Barker, who rec- 
ognized the deformity, which was probably due to exostosis, 
and we agreed perfectly in om^ views of the operative proce- 
dure, viz., forceps first, and if they failed, version. Pulse 70. 
Condition of patient excellent. Anterior lip, however, down 
before the head, and oedematous, though readily replaceable. 
At 10 p. M., then, things being in this condition, no advance 
having been made, the head above the brim dipping the arc 
of parietal bone formed by the plane of the brim alone into 
the superior strait of the true pelvis, I applied my forceps, 
which were promptly adjusted and locked. I then made 
traction with all the strength which my arms afibrded, sitting 
at one time on the fioor and pulling in the direction of the 
superior strait with all my might. During one of these 
efforts I felt them slip slightly, and instantly stopping, re- 
adjusted them, and continued until we were satisfied that 
traction was of no avail. 

I then withdrew the forceps, and passing my left hand 
within the uterus, brought down the right foot. This was 
not sufficient, as the other caught above the pubis, and was 
brought down with some difficulty. The hips being deliv- 
ered, the cord was found to pulsate feebly. The arms were 
readily brought down, but no manipulation would suffice with 



856 OBSTETRIC CLINIC. 

the head, which haying necessarily turned with the sagittal 
suture parallel to the transverse diameter of the pelvis, hap- 
pened so to close the right side as to forbid all hope of intro- 
ducing the second blade of my forceps. The cord had now 
ceased to pulsate. Being by this time pretty well fatigued, 
Dr. Barker endeavored to bring the head through, but it was 
too firmly wedged to pass. I then introduced the perforator 
midway between the occipital protuberance and the mastoid 
process, and rattled Churchill's crotchet freely about within 
the cranial ca^dty. I then tried to introduce Dr. Thomas's 
ingeniously contrived craniotomy forceps, but though the 
blades are only the breadth of the middle finger, there was 
absolutely no chance for the second blade. Having then 
hooked the crotchet firmly over the occipital bone. Dr. Bar- 
ker and I relieved each other in our tractions. He made two 
efforts, and in my third the head finally passed, one hour 
and fifteen minutes after the commencement of the operation. 
The woman recovered perfectly, though there was puer- 
peral fever in the house at the time, justifying, thus, what I 
sincerely believe to have been excellent practice, viz., com- 
mencing the operation before the patient was exhausted by 
fruitless efforts, and reflecting great credit on Dr. Andrews 
for discovering and appreciating the pelvic deformity when 
he did, instead of simply satisfying himself that there was a 
head presentation in a woman who had borne a living child. 

Case 155. — Contraction of antero-jposterior diameter of 
trim / forceps / version • jperf orator. 

This was a case to which Dr. McLeod, then Resident 
Physician of the Lying-in Asylum, was called in consulta- 
tion, Dr. Powers being in attendance. 

The deformity was such that the finger readily enough 
reached the promontory, when passed along the plane ex- 
tending to the lower part of the pubis. Her first child had 
been force-delivered and still-born ; she was now at term ; 



VERSION". 357 

and after a tedious labor, Dr. McLeod had applied forceps, 
tlie head not being engaged within the brim, and had failed 
to advance it. He then performed version, a difficult task in 
this case, with a large male child to contend with, and had 
bronght away the trunk without injury, but could not advance 
the head by any traction. Failing entirely with the hand, 
and the child being dead, with the chin to the right ilium, 
he introduced the crotchet in the right orbit, and made strong 
traction, until the orbit and malar bone yielded before the in- 
strument down to the alveolar process. He then requested me 
to see the case. She was under the influence of chloroform, 
administered by Dr. Powers. The woman's condition was 
good, and I tried manual efforts, as I have in these cases 
until I have felt and heard the bones of the neck crack, and 
without avail. With the permission of the gentlemen, I 
applied my forceps, and hung on it awhile to no purpose. 
In this case the blades could be readily introduced, so capri- 
cious are these cases, and there being nothing left in the 
right orbit to pull on, I proceeded to introduce Dr. Blot's. 
My reason for not using it at once was chiefly the position 
of the head. It was so high up, and so locked, that there 
remained but the choice of two places for perforation : one 
through the mouth, with the risk of its slipping through the 
hole made by the crotchet ; and the other through the occi- 
pital bone, between the protuberance and the mastoid pro- 
cess, and here the entrance of the point could not be guarded, 
and the axes of the head had to serve as guides. Having 
opened the head and evacuated the brain Churchill's crotchet 
did the rest, the base of the occipital bone giving a capital 
pm'chase in these cases. 

Se^temler 20th. — Patient recovered perfectly. 

Case 156. — Transverse presentation j difficult version^ 
prolapse of funis. 

M. "W , single ; aged 25 ; number of conflnements not 

stated. In labor March 9, 185T, for nine hours. Male child 



358 OBSTETEIC CLIXIC. 

still-born — ^niue pounds eleven onnces. J. Smitli Dodge, Jr., 
House Physician. 

At 11 A. M. Dr. Dodge found this patient .in labor with 
regular pains and in good condition, and detected the left 
hand presenting through the unbroken membranes. Os the 
size of a dollar, long diameter of uterus oblique, fundus to 
the right. Foetal heart loudly audible over median line 
just below the umbilicus. At 4. p. m., as the cervix was not 
fully dilatable, I directed the injection of fom^ or -Rye quarts 
of warm water just within the os, when the cervix promptly 
relaxed and became fully dilatable. At 5 p. m. the hand 
only being within reach, I attempted version. On rupturing 
the membranes the cord instantly prolapsed to the vulva. I 
grasped the right foot with facility and brought it down to 
the vulva, hy which time the cord had ceased to pulsate. All 
my efforts could not move, the foetus ftu'ther. Dr. Dodge, 
who assisted me ably, failed also. As the child was dead, I 
tried with a poor paii- of craniotomy forceps to advance the 
leg while rolling the child away from the brim, but did not 
succeed. Fillet failed. Stopped then and sent for fiu'ther 
aid, and Dr. Taylor arrived at a quarter of six. Hand, foot, 
and funis in the vagina, head to be felt above the brim. I 
then made another effort to get down the left foot, and aided 
by traction with a good pair of craniotomy forceps we suc- 
ceeded in completing this difficult delivery. Placenta came 
away readily, uterus contracted well. Labor terminated at 
7.40. Came promptly from under chloroform. Pulse 90. 
Condition good. Ergot and then morphia. 

lO^A. — Comfortable, pulse 84. Much soreness and swell- 
ing. House physician did not succeed with catheter, but 
relieved the bladder with fomentations. 11th. — ^Pulse 120, 
tongue rather diy. IS^o better success with catheter ; doubt- 
ful about amount of water passed. Hands and feet cold, 
mind unclouded. Opium, camphor, and brandy. In the 
afternoon the face became distorted, breathing difficult, and 
she died rather suddenlv. 



VERSION". 359 

Autojpsy. — Heart, liver, and kidneys, in advanced fatty 
degeneration, appearances confirmed by Dr. Dodge's micro- 
scopic observation. Spleen almost pnltaceons, and of claret 
color. Microscope sbows fibro-plastic cells, free nuclei of 
splenic cells, bnt no pus. Uterus relaxed, not apparently 
inflamed. Bladder mncb injected, containing some opaqne 
mnco-puriilent matter. Peritoneum injected arborescently, 
and in one place a small patch of recent lymph. 

Case 157. — Presentation of nape of neck and shoulder in 
a contracted pelvis ; version; Uimt-Jioolc. 

Bridget ^N'ngent, aged 22. Third confinement, April 22, 
1859, Lying-in Asylnm, Duration of labor, sixty honrs. Dr. 
Cock and I saw this patient at the request of the Eesident 
Physician, Dr. Wilson, and recognized an under-sized conju- 
gate diameter, which might, however, reach three and a half 
inches. When seen the waters had been evacuated fifty- 
three hours, and no foetal heart was audible. The presenta- 
tion was obscure ; it was either a natis or a shoulder ; one 
limb attached thereto could be made out, and it was decided 
to draw it down for confirmation of the diagnosis. The 
patient having been brought under chloroform, I succeeded 
in doing this, after fracturing it at the commencement of my 
manipulation, when it proved to be the right arm, with the 
palm directed anteriorly when the radius and ulna were in 
the same plane, showing that the abdomen was directed an- 
teriorly. On the withdrawal of the arm, an escape of very 
offensive discharges occurred. I then introduced my left 
hand and reached a foot, which I could not bring down. 
The impediment was found to be the head, which was flexed 
in a most exaggerated manner, the chin far down on the 
breast-bone, the head thus occupying the hypogastric region, 
and the nape of the neck being one of the presenting parts. 
I proposed to ^n the head by a blunt-hook passed over the 
neck, and then to perforate and deliver by cephalic version. 



360 OBSTETEIC CLINIC. 

Dr. Cock preferred podalic yersion, and brouglit the left foot 
to tlie Yiilva. Unavailing efforts were then made by both of 
ns to complete the version, which failed, although Dr. Cock 
so arranged a iillet as to enable it to bear his weight. After 
this, we both used traction with craniotomy forceps, until 
the foot and malleoli were crushed. I then exhausted my- 
self in successfully pushing the head up on the left side of 
the uterus, when Dr. Cock brought down the right foot, and 
delivered to the. umbilicus, when he yielded from fatigue, and 
I succeeded in completing the delivery, though only with the 
blunt-hook in the mouth and fracture of the jaw. 

Remarlis. — In our experience an exactly similar case has 
never occurred, nor can a more difficult case of version be 
met with than this proved to be. It is possible that an 
original head presentation was converted into one of the 
right shoulder and nape of the neck from failure of the head 
to dip within the brim, and thus passing upon the anterior 
wall of the cervix, so as to become flexed on the chest in an 
extraordinary manner, as could be demonsti^ated after de- 
livery. This flexion became increased possibly by flexi- 
bility of the articulations after the child's death. !No post- 
mortem examination for fracture or dislocation. The region 
over the right acromion process and spine of scapula then 
became so enormously swollen as to obscure their distinctive 
features. The operation was one of the extremest difficulty, 
on account of the contracted pelvis, the very great length 
of time (fifty-three hours) since the waters were evacuated, 
the size of the male child, and the extraordinarily wedged 
position of the head, which so long defied our efforts for its 
dislodgment. 

Subsequent history of the case. — The following report is 
furnished by Dr. "Wilson, resident physician of the asylum, 
who attended the patient. I saw her two or three times, and 
had an opportunity of confiiming the diagnosis of pleurisy 
and of the physical signs of phthisis. 

After delivery patient week and feeble. Gave brandy 



VERSION. 361 

and ergot until tlie litems contracted well, and then gtt. xx 
of Magendie's solution of morphine. 

Api'il 22<rZ, 9 a. m. — Pulse frequent and small. Two 
grains of opium every foui* hours. 12 m. — Pulse 90. Com- 
fortable. Passed water with difficulty. Spts. seth. nit. dulc. 
6 p. M. — Pulse increasing. Tinct. verat. viride four drops 
every four hours. Midnight. — Pulse 100. 

Aj}ril 2M, 9 A. M. — Pulse 120. Discharges offensive. 
Tongue diy. Skin hot. Tinct. verat. viride ^yq drops, and 
foiu' grains of opium every four hours. Noon. — Pulse 98, 
full and bounding. Face flushed. Poiu' grains of opium 
every three hours. Yerat. viride as before. T p. m. — Pulse 
76. Soft, gentle perspiration. Tongue moister. Consider- 
able tenderness over uterus. Complains of pricking sensa- 
tions over the body. 

April 24:th, 9 a. m. — Slept a little during the night. 
Pulse 80. Pains over epigastric region. Tongue has a 
brovTiish-yellow coat. Pespiration about normal. Passes 
water freely. Lochia free. IsToon. — ^Pulse 100. Skin moist. 
Tenderness over abdomen. Tympanitis. 3.30 p. m. — Pulse 
101:. Skin dry. Tongue more dry. More tenderness. Pive 
grains of opium every three hours. Tinct. verat. viride gtt. 
vj every four hours. 7 p. m. — Skin dry. Pulse 98. 

April 26t/i, 1 A. M. — ^Pulse soft. Skin moist. 9 a. m. — 
Has slept a little. Feels sore. No pain. Pulse 84. Dis- 
charge free, not so offensive. 9 p. m. — Has passed a com- 
fortable day. Pulse 90, soft. Yery little tenderness. Skin 
moist. Lochia and milk free. Small doses now of opium 
and veratrum viride. 

April 27th. — Has been doing well. Tongue cleaning. 
Pulse 90. Skin moist; but the window having been left 
open she had a chill and at noon pulse 100, bounding. Ye- 
rat. viride gtt. iv. Opium increased. 2 p. m. — Pulse 110. 
Face flushed. Skin dry. Secretions arrested. Some tender- 
ness. Five grains of opium and three drops of verat. viride. 
4.30 p. M. — Pulse 100. Free perspiration. 5 p. m. — Four 



362 OBSTETEIC CLINIC. 

grains of opmm and four drops of yerat. yiride. 7.30 p. m. 
— Pulse 78, soft and full. Skin moist. Comfortable. Med- 
icine to be continued p. r. n. 

April 2Sth, 6 a. m. — Stopped medicine, doing well. 

May 2d. — Dysentery. Typlioid symptoms threatening. 
Brandy and quinine. Bowels controlled by injections. 

Jfay 4cth. — Doing tolerably well. 

May 6th. — Four or five evacuations, watery, brown in 
color. 

Jfay 6th. — Eight evacuations in the night, yellow curds, 
offensive. Much prostrated. 

May 7^A.— Better. 

May 8th. — Three or four a day. Mucus, slimy, tinged 
with blood. Tongue glossy. Pulse 100 and feeble. Much 
pain from swelling over the site of the parotid gland. Mat- 
ter subsequently formed, and was evacuated. 

May dih. — Feeble. Bowels less frequently moved. Tinct. 
opii gtt. XXX and nourishment. 

May 10th. — About the same. 

May 11th. — ^Evacuations more frequent. Extract of log- 
wood. 

May 12th. — Bowels only moved once last night. 

May 16th. — Has continued to improve, but now presents 
symptoms of inflammation of the right pleura, which was 
promptly checked. Cough continues. Examination dis- 
closed physical signs of phthisis. 

May 26th. — Has continued to improve gradually. In- 
sisted on leaving the asylum to return to her husband, in 
spite of Dr. "Wilson's urgent remonstrances. 

May 28th. — Has been doing well at home until about 
noon, when she was seized with difficulty of breathing and 
died very suddenly. !N"o physician with her. l!To post-mor- 
tem allowed. ((Edema glottidis ? )^ 

* Tide Reports of the New York Academy of Medicine for 1857 and 1858 
for a full discussion of Puerperal Fever, by Profs. Alonzo Clark, Fordyee Barker, 
the late Joseph M. Smith, and others. 



VEESIOIT. 363 

Case 158. — Ohliqiie cranial fvesentation from left ute- 
rine oMiqiiitij ; forcejys ; iKrfoi^ator. 

Catliarine Eegan ; 27 ; second confinement ; tliirty-tliree 
lionrs in labor. Female cMld. This patient was delivered 
in tlie ]^ew York Lying-in Asylum, May 12, 1859. "When 
first seen by Dr. Thomas F. Cock, one of the physicians of 
the asylum, and myself, the uterine tumor was very oblique- 
ly inclined with the fundus to the left side, and the child's 
head was pressed firmly against the right linea ilio-pectinea, 
and the iliac fossa. Exact position obscmed by the caput 
succedaneum. Brim somewhat under-sized, as the promon- 
tory could be too readily reached. Patient in an excellent 
condition. Foetal heart audible. 

The alternatives of version, the lever, and the long for- 
ceps having been carefully considered, it was decided to keep 
the patient on her right side, and retain the uterine axis in 
correspondence with the long axis of the body by a bandage 
and compress, in hopes that the leverage thus exerted might 
dislodge the head and permit its descent. In the event of 
this not occurring by the morning 'the consultation was to be 
summoned again. On the following afternoon. Dr. Wilson, 
the resident physician, sent for us again, and at 8 p. m. Dra, 
Borrowe, Cock, and I arrived. Dr. Lee Jones was also pres- 
ent. At this time the head had moved from the right iliac 
fossa, but was firmly pressed against that side of the brim. 
Caput succedaneum very large. Foetal heart now inaudible, 
though Dr. "Wilson had heard it at 5 p. m. Under these cir- 
cumstances it was decided to attempt delivery with the for- 
ceps, room for which could only be obtained in fi-ont of the 
right sacro-iliac synchondrosis, and behind the left acetabu- 
lum. I therefore applied the forceps, and carried the first 
blade directly to its position without the customary spiral 
sweep — which would have been impossible — and used every 
effort to advance the head without effect. When all were 
satisfied that such efforts were fruitless, I perforated the head. 



364 OBSTETRIC CLINIC. 

Great difficulty was experienced in withdrawing the head 
even after complete evacuation of the brain, and the blunt- 
hook was necessary for both shoulders, nor did the pelvis pass 
without assistance. Placenta came away readily. E'o hem- 
orrhage. Chloroform. Patient made a good recovery. 

Fracture oflinibs inversion^ or in original pelvic presen- 
tations, — These accidents are sometimes unavoidable. They 
may occur in a foetus with intra-uterine rachitis, in whom 
these fractures sometimes occur spontaneously and in re- 
markable numbers, as in a case related by Chaussier. The 
articulations may be by synostosis, and intra-uterine disease 
may have diminished or abolished the normal mobility of the 
joints. 

They may occur from carelessness or faulty manipulation, 
and they may be the result of design. In children known 
to be certainly dead, one or more extremities may be pur- 
posely and unhesitatingly broken to facilitate the delivery ; 
and this may be intentionally done to increase the chances 
of the child's life in conditions of danger. 

I have heard the femur snap dming gentle tractions with 
the fillet, made by most skilful hands abroad, and have seen 
a living child delivered by version with both clavicles frac- 
tm'ed in Great Britain. Cases are given in this work where 
I have designedly fractm-ed the arm, leg, and jaw of children 
known to be dead, with the blunt-hook or hand. 

In cases where the child's life will be lost unless the 
delivery be promptly terminated, the fractm'e of an extremi- 
ty is a very slender price to pay for success. And while the 
necessity for this contingency should occur but seldom, it 
must be promptly recognized and boldly met. 

It has never occurred to me to fracture any other ex- 
tremity in living children than the arm, and this has always 
■united in a prompt and satisfactory manner without de- 
formity ; and so have other fractures in the neonatus which 
have come under my observation. 



VERSION. 365 

Case 159. — Yersionfor transverse ^presentation j fracture 
of right arm / forcejps. 

Kate Browii, aged 27, second confinement; fell in 
labor July ^'^^ 1S59, at 8 a. m., Bellevue Hospital, mider tlie 
care of Dr. Reuben Cobb, House Physician, who recognized 
a transverse presentation, left shoulder presenting, head in 
right iliac fossa. I arrived at half-past 10 a. m., and the 
patient being nnder chloroform, delivered a living male 
child, weighing eight and a half pounds, by podalic version. 
The arms and head were retained above the brim, and I pur- 
posely fractured the right arm in drawing it down. Manip- 
ulation of the head being unsatisfactory, I delivered promptly 
with forceps and saved the child. The fracture was treated, 
I believe, by Dr. George Johnson, now of Brooklyn, then 
one of the house surgeons of the hospital. The mother did 
well. 

Case 160. — Forceps; occipito-^posterior presentation; 
fracture of arm. 

In a case of a primipara, seen with me by Prof. J. T. 
Metcalfe ten or eleven years ago, the head had failed to ad- 
vance for more than six hom'S, and we proceeded to deliver 
with forceps. The head was in an occipito-posterior position, 
which, however, was not recognized, and the delivery was 
very difficult indeed. "We relieved each other in our trac- 
tions, and finally succeeded when we were quite tired out. 
The child was a very large boy, weighing over thirteen 
pounds on the following day, and we fractm^ed the arm with 
a blunt-hook in completing the delivery. The mother recov- 
ered without an unfavorable symptom, and the boy is now 
alive and hearty, the fracture having promptly united with- 
out any trace of deformity. 



CHAPTEE XIII. 



rNTFLA:W]MATOET COMPLICATIONS IX THE SURGICAL TREATMENT 
OF THE DISEASES OF WOMEN. 



Risk of developing inflammatory complications in the surgical treatment of 
women. — Carbolic acid. — Case: Retroverted uterus, with ovaries in the 
cul-de-sac forbidding the use of a pessary. — Use of pessaries. — Case: Re- 
troversion of an hypertrophied uterus, with dangerous menorrhagia ; benefit 
from pessary. — Cases illustrative of the tolerance of pessaries improperly 
applied. — Case : Pelvic cellulitis not connected with the puerperal state ; 
rapid recovery. — Open air and sunshine in the diseases of women. — Case: 
Cystitis, peri-cystitis, peri-nephritis in a virgin. — Case: Cellulitis of abdomi- 
nal wall in a virgin. — Remarks. — Case: Pelvic cellulitis and suppuration 
following sponge-tents. — Should pelvic abscesses from cellulitis always be 
opened ? — Case of pelvic abscess opening into the peritoneal cavity. — Pelvic 
fistula. — Case: Abortion; metritis; hypertrophy of uterus. — The practice 
of abortion in this country. — Necessity for more hospitals. — Nursery and 
Child's Hospital. — Topical abstraction of blood from the uterus. — Beware 
of pregnancy. 

The risk of developing inflammatory complications in 
the surgical treatment of the diseases of women. — The devel- 
opment either of metritis, of cellulitis passing possibly into 
suppuration, or of peritonitis, are risks which overshadow 
the surgical treatment of the pelvic organs in women, and are 
always kept in mind by the wary practitioner. Some of 
these dangers may be averted and others cannot, but in either 
event their early recognition is essential for the satisfaction 
of the practitioner and the benefit of the patient. Among 
the influential causes which are difficult to avert, and against 
which we have to contend in Bellevue, is the atmosphere of 



CAKBOLIC ACID. 367 

a large general liospital, to wliicli medical, surgical, and ob- 
stetrical cases are admitted. We find the results in tlie fre- 
quently recurring pelvic cellulitis of tlie post-puerperal state, 
to which the attention of the class has already been drawn, 
and which can be clinically demonstrated during each suc- 
cessive service. But in the surgical treatment of uterine 
disease the practitioner is often obliged to reject or to post- 
pone methods of treatment which would undoubtedly be of 
service, if hygienic, atmospheric, or constitutional conditions 
were not recognizable and adapted to render these methods 
hazardous, if not dangerous. 

Carholio acid. — During the past year the wood-work of 
the lying-in wards of Bellevue has been dampened every 
day with a weak solution of impure carbolic acid. Dr. Done 
informed me that one of the professors of the Smithsonian 
Institute had expressed his confidence in its ability to destroy 
the germs of infection, and I introduced it in the hospital. 
Certainly we have had much less puerperal fever and in- 
flammation since it has been employed. 

So many women with chronic inflammatory aflections of 
the uterus and pelvic organs are the subject of complicating 
cellulitis varying in extent and severity, that before any 
active measm^es are employed the whole pelvis should be 
explored as thoroughly as possible, in order to be sure that 
no evidences of cellulitis or peri-metritis can be found. The 
serious consequences which have so often followed the intro- 
duction of pessaries, sponge-tents, and exploring instruments, 
as well as the application of strong cauteries and milder 
medicaments to the uterus, might often have been obviated 
by the selection of the gentler methods of treatment alone 
permitted by the preexisting pelvic inflammations. 

Perhaps one of the greatest and most frequent mistakes 
committed by those who are commencing the local treatment 
of the diseases of women, is the neglect to appreciate other 



368 OBSTETEIO CLIKIC. 

conditions of tlie pelvic organs than those of the nterns alone. 
Careful conjoined, or bi-mannal, manij^nlation of these parts, 
and the preliminary employment of all methods of examina- 
tion, will often lead to the final rejection of methods of treat- 
ment which previonsly suggested themselves as the best, but 
which are seen to be too hazardous for the special case under 
consideration. 

Case 161. — Retroverted uterus with ovaries in the cul- 
de-sac forbidding the use of a pessary. 

Thus in the patient in this bed, with a retroverted uterus, 
not hypertrophied, susceptible of reposition, but dropping 
down again into the cul-de-sac when the lifting force is with- 
drawn, there would be no method of treatment which, in 
my judgment and in my hands, would probably compare 
with the use of an accurately-fitted Hodge's closed pessary. 
But it is interdicted in her case by the presence of both ova- 
ries in the cul-de-sac. These are not enlarged, not adherent, 
not inflamed. But they are there, and they are in the way, 
and they cannot be gotten out of the way just now, although 
this result may frequently be brought about in favorable 
cases ; and the pessary could not push up the fornix^of the 
vagina, and keep the . uterus in its place, without pressing 
upon them ; and if their presence were not recognized, if the 
dislocation were reduced, and the instrument then applied, 
while the ovaries were in the cul-de-sac, no matter how well 
it might be otherwise adapted, in a very short time it would 
have to be withdrawn on account of the pain it would pro- 
duce, even if its presence had not already lighted up inflam- 
matory conditions of the ovary, or of its appendages, or of 
the cellular tissue, which might more or less seriously com- 
plicate the future of the patient. 

On the other hand, by abstaining from such treatment 
now, and by replacing the organ from time to time, prescrib- 
ing for any indications, and aiding treatment by recom- 
mending such positions in bed as will favor the removal of 



PESSAEIES. 369 

the OYaries from the cul-de-sac, the time may come ^hen 
the field is imobstructed, and the instrument may be intro- 
duced and worn with the greatest benefit, and with the re- 
sult, possibly, of a permanent cure. 

A number of such cases have occurred to me. They are 
not infrequent, and, in my opinion, they are often over- 
looked, and are one of the avoidable complications which 
have tended to bring pessaries into disrepute. Indeed, when 
one reflects how difficult it is to find a ready-made boot 
which will fit a sensitive foot, one has no difficulty in appre- 
ciating the delicacy of the task of adapting an unyielding, or 
comparatively unyielding instrument to such delicate tissues. 
With this fact before your minds, never fail to be sure that 
neither the ovaries nor local inflammatory products are liable 
to be pressed on by a pessary ; and beware of lighting up 
the smouldering embers of any pelvic inflammation by this 
or any other treatment however well adapted to obvious 
conditions of disease in neighboring parts. 

Use of pessaries. — In a large proportion of the cases of 
retroversion and of retroflexion of the uterus which come 
under my care, I am in the habit of using the pessary of 
which I have spoken ; but never without this careful prelim- 
inary examination, and never without directing that it should 
be examined, or withdrawn, at the first sign of pelvic dis- 
turbance. Theoretically, I would greatly prefer Scatter- 
good's pessary, were it not for the unavoidable foetor which 
attends its use, and imperatively demands its frequent with- 
drawal for cleanliness. There are cases to be met with in 
which other forms of pessaries are better adapted, and some 
in which a better instrument may be made at the bedside 
by a skilful twister of flexible metal. 

But, as a law, my experience leads me to be satisfied 
with the various forms of Hodges' pessary (closed) which the 
India-rubber makers give us, and which can be readily se- 
lected, or bent into the proper shape. While, however, the 
24 



3Y0 OBSTETEIO CLINIC. 

utmost caution is demanded for their selection, adaptation, 
and trial, I often meet with patients who wear them con- 
tinuously with benefit and impunity for months and eyen for 
one or two years; passing the summer in travelling, and 
crossing the Atlantic with them in situ. 

Case 162. — Retroversion of an hypertrophied uteruSy 
with dangerous inenorrJiagia ; 'benefit from pessary . 

One patient of mine, subject to hemorrhages of the most 
alarming character, whose uterus was enlarged and greatly 
retroflexed, flowed on one occasion until there was no radial 
pulse and she had sunk into syncope. Her safety demanded 
the most active treatment. Dr. "Wynne, Dr. George A. 
Peters, and Dr. Marion Sims saw her with me then and 
subsequently. I was obliged to tampon the vaginaj com- 
press the femoral arteries, hold up the arms and legs, and 
administer beef-tea and stimulants lavishly by the mouth 
and by enemata, to save her life. Yet, after these immediate 
dangers had passed, and the uterus had been replaced, and 
kept in position by a well-fitting Hodges' closed pessary, 
very little subsequent treatment was necessary ; and so great 
was the comfort that the patient experienced from the treat- 
ment, that she would never allow the instrument to be taken 
out of the vagina for a moment during eighteen months ; and 
now, after the lapse of five or six years ; she looks back on the 
introduction of the pessary as the turning-point in the his- 
tory of her case. Before this time she had been abroad for 
advice, and had twice received benefit in Paris from the ac- 
tual cautery. 

Tolerance of pessaries improperly used. — It must be 
remembered, however, that the presence of a badly-fitting 
pessary, which has occasioned marked pelvic cellulitis, may 
still be supported by the inflamed and patient organs. 
Thus, last winter I removed, before the class in this hos- 
pital, a large circular box-wood pessary, perforated with 



PESSAEIES. 371 

small lioles, from tlie vagina of a German woman, wliich 
was fitted into a groove formed in the pelvic tissues, and 
tliese were so hardened by pelvic cellulitis as to feel like 
wood. There was no suppuration in the cellular tissue, or 
ulceration of the vagina, and the woman w,as able to walk ; 
but the pessary had begotten an attack of cellulitis of the 
most general character, and which forbade vaginal manipula- 
tion of the pehdc organs. Dr. Shekleton told me that a 
woman once entered the Dublin Lying-in Hospital, of which 
he was Physician-in-chief, with the signs of pregnancy and 
labor. The pupil on duty recognized something very ab- 
normal in the presentation, and a box-wood pessary was 
withdrawn which had been inserted before conception, and 
had remained there without the knowledge of the patient. 
The situation in these cases of cellulitis may be described 
by a simile, which seems to me not inapposite. The healthy 
uterus and appendages float in the pelvis as easily as a ship 
at her moorings ; but, while the ship may be fastened in one 
position by the fi-eezing of the stream, so may a general pel- 
vic cellulitis fasten the uterus in situ, and either limit or 
forbid its movements. And, as the fastened vessel may be 
careened by the new forces, so may the uterus be deflected, 
bound down, elevated, or depressed by the varying sites, or 
amount of the effusion into the areolar tissue. 

An example of these influences and results may be found 
in the patient in an adjoining bed, with the following his-, 
tory. Her case illustrates emphatically the occurrence of 
cellulitis without any known cause, and resolving with grati-- 
fying and prompt success under treatment. 

Case 163. — Pelvic cellulitis not connected with thefuer- 
jperal state / rwpid recovery. — Dr. Nicoll^ House Physician. 

Catherine Hanna, aged 20 ; United States ; married ; 
seamstress; admitted into Bellevue April 1, 186T. Two 
weeks before, she had been seized with great pain in the 



3Y2 OBSTETRIC CLINIC. 

lower part of the abdomen wMcli had persisted, and she had 
suffered great pain in micturition dmiug the last week. 
She cannot explain the cause of her symptoms. Yaginal 
examination discloses increased heat and sensibility of the 
vagina. Urethra normal. At the junction of the urethra 
with the bladder a rounded tumor is felt, which is hard, and 
extends across the right side of the vagina, diminishing in 
size, and reaching nearly to the right ischiatic spine, where 
it seems to be in intimate relation to the pelvic wall. It also 
passes to the cervix uteri, and seems to have pushed that 
organ toward the spine of the left ischium. The tumor has a 
hard woody feel, and is very sensitive. Through the poste- 
rior cul-de-sac a similar swelling connected with the first can 
be felt. The tumor can be clasped between the fingers in the 
vagina, and the fingers above Poupart's ligament, the blad- 
der being empty. The case was diagnosticated as pelvic 
cellulitis, and the bladder directed to receive special atten- 
tion. The bowels were moved by castor-oil, warm poultices 
were kept on the abdomen, and five grains of the iodide of 
potassium were given three times a day. April Mh. — She 
now passes urine without pain. The abdominal poultices 
were replaced by cotton covered with oiled silk. There is 
less tenderness. lO^A.^Tenderness gone. Feels well. Still 
kept in bed. 24;^A.— Careful vaginal examination and con- 
joined manipulation ascertain that the induration has entirely 
disappeared. The parts are perfectly normal. Treatment 
discontinued. 27^^. — Discharged cured. 

Bemarks. — Here, then, is a case of pelvic cellulitis 
promptly terminating in recovery, and originating in influ- 
ences unknown to us, and certainly not related to any of 
those which we have been considering. "When the patient 
was first admitted, I was apprehensive that the relations of 
the effusion to the bladder and the difficulty of mictm^i- 
tion might indicate some vesical complication, or that 
the whole trouble might depend on disturbances of the 
bladder. And accordingly the urine was drawn with the 



PELTIC CELLULITIS. 



373 



catlieter immediately after micturition in order to prove 
tliat tlie bladder was thoronglily emptied, and carefully ex- 
amined with tlie microscope to prove tliat it was liealtli}^ 
"Wlien tliis element of clinical interest was tlioronglily elimi- 
nated, tlie cellulitis alone was left to treat ; nor would I liave 
been quite willing that a siugle point of the treatment should 
have been omitted. The absolute rest in bed to prevent the 
risk of exposure to cold, and the strain of the erect position : 
the mild laxatives to prevent the accumulation of hardened 
faeces and the imtation from their passage ; the careful atten- 
tion to the bladder ; the warm applications to the abdomen 
which so greatly relieved the pain ; and the iodide of potas- 
sium — all contributed to ward off present risks, and promote 
her restoration to health. 

With regard to the iodide of potassium, I am free to con- 
fess that my habit of prescribing it in these cases may savor 
of routine ; but such cases as the one just detailed, which 
have given me the most marked examples of rapid recovery, 
have been those in which this agent has been employed. 
From the year 1850, when Sir James Simpson, in the 
exercise of his prodigal hospitality and unwearied kind- 
ness, fii'st taught me to appreciate pelvic cellulitis by the 
touch, my hospital and private opportunities have never 
allowed me to pass much time without its recognition ; 
and I am very confident of the fact that I see suppuration 
follow pelvic cellulitis less frequently during the last eight 
or nine years than before I gave the iodide. At all events, 
if I am mistaken, or if the facts are attributable to other 
influences, still the agent can do no harm ; and I am 
specially desirous of not recommending it unduly, for no 
healthier medical habit can be encouraged for myself or for 
my medical brethren than that of skepticism regarding the 
effects of drugs, until their value and their uses shall have 
been triumphantly demonstrated. I shall never forget the 
rapid improvement which followed the use of the iodide in 
one poor woman, in this hospital, with extensive pelvic eel- 



874 OBSTETEIC CLINIC. 

lulitis, which had suppurated, and had opened into the vagina, 
the rectum, through the abdominal wall in several places, 
and bj fistulous tracks below Poupart's ligament. 

Benefits f 7' om exercise in the open air and sunshine in the 
diseases of women. — Do not let my remarks be misunderstood 
regarding the advantages of rest in bed in these cases ; and 
indeed those which I am about to make are capable of a much 
wider range of application. The sedentary habits, household 
opportunities, and freedom from ont-door engagements of 
women, facilitate and encourage a habit of remaining in bed 
for relief from pain, and the habit is too frequently indorsed 
by medical advice, since it may result in the most unfortu- 
nate moral and physical invalidism, and often develops the 
germs of latent tubercular predisposition. We have always 
to struggle against this tendency in these wards. Leaving 
out of consideration that large group of cases for which the 
best physician is he who can best tempt the patient to the 
enjoyment of suitable exercise in the sunshine and open air, 
and confining my remarks to the cases before us, we must 
remember that the rapid improvement of Catharine Hanna 
can neither be always attained, nor even hoped for. For many 
of these patients,many months of intelligent supervision are 
essential elements in the problem of recovery, and while dur- 
ing much or all of this time the risks of suppuration are 
imminent or recm-ring, the general health could scarcely fail 
to be seriously and perhaps permanently impaired by con- 
finement to the room or bed. I have often wished that my 
patients might be carried in sedan-chaii'S and litters through 
the streets without attracting observation and remark, or even 
that Bath-chairs were in fashion at our watering-places ; for 
some of these patients cannot ride in carriages. The Hon. 
Mrs. Skewton had privileges which would be priceless to 
many invalids. In the house and in one's own grounds, 
however, this indication may be met in various ways, and 
must always be kept in view ; while the grand boulevard of 



CYSTITIS. 375 

water wliicli surrounds our cit j offers tlie pleasantest method 
of transition from its heated walls and crowded streets, to the 
sea-shore or to the inland woods. 

The complication of cystitis in these cases may be forci- 
bly illustrated by the history of the following case, which 
came into my wards last September, and the results of the 
autopsy were shown to the class in attendance on my clinical 
lectm^es : 

Case 164. — Cystitis^ jperi-cystitis, and peri-nej>hritis in 
a virgm.^ — Dr. Herman Smithy Souse Physician, 

H I ; unmarried ; aged 23 ; native of ITew 

York; admitted to BelleYu.e September 11, 1866. The 
patient is well built, and states herself to have enjoyed per- 
fect health until six weeks before admission, when she suffered 
from unexplained retention of the urine for twenty-four hours. 
There is no suspicion of tubercular tendency. These dis- 
turbances then ceased entirely for a fortnight, when she began 
to suffer from lancinating and bearing-down pains in the pel- 
vis, which have been so severe during the past fortnight as to 
keep her in bed. During this time the urine has constantly 
dribbled from her, and her bowels have been much confined. 
About three weeks ago she noticed a tumor in the hypogas- 
tric region, which has been gradually increasing in size. 
When admitted, the expression of her face was haggard, and 
of unfavorable omen. Skin cool, pulse small and frequent, 
tongue heavily coated with a brown fur. Yomits frequently. 
There was a hard smooth tumor just above the pubes, reach- 
ing half way to the umbilicus, broader above than below. 
This was somewhat tender. Yaginal examination detected 
a moderately retroverted uterus, and a hard bulging tumor 
on the anterior wall of the vagina. Three pints of bloody 

* Vide " Clinical Remarks on Certain Affections of the Bladder in Women," 
by the author, in the New York Medical Journal for April, 1867. 



6ib OBSTETEIC CLDsIC. 

and veiy offensive urine were di'avni by the catlieter, when 
evidences of peri-cjstitis were recognizable thi'ongli the ante- 
rior wall of the vagina, especially toward the ontlet. Twelve 
hours after, a pint and a half of bloody and offensive ui'ine 
were withdrawn by the catheter, and found to contain blood- 
corpuscles, pus-coi-puscles, and quantities of vesical epithe- 
lium. The patient entertained a horror of the catheter, 
screaming in the most piteous manner from the pain of the 
gentlest manipulation ; still the catheter was used much more 
frequently, and the bladder washed out with medicated injec- 
tions. TTaiTu poultices were kept on the abdomen, the skin 
excited by the hot-air bath, and stimulants were given. 16ih. 
' — Urine less foetid and bloody, and somewhat diminished in 
quantity. Sm-face cold and blue. Scarcely any pulse at 
wrist. Persistent vomiting. Intellect clear. 17th. — Xo 
marked change, except that she is obviously weaker. Beef- 
tea and whiskey given by enemata. Urine less foetid, and 
much diminished in quantity. She steadily continued to 
sink, and died at T a. 31. of the 20th, having survived .much 
longer than had been anticipated from the symptoms of 
collapse. 

The autopsy was made six hours after death in the pres- 
ence of Prof. Yan Bm-en. On opening the abdomen some 
coils of small intestine, and part of the omentum, were found 
attached by adhesion to the posterior and superior portion 
of the bladder ; slight adhesion of the walls of the Douglas 
cul-de-sac ; the connective tissue between the pubes and the 
bladder much thickened ; internal surface of the bladder very 
■gi'eatly congested, softened, of a dark color, and presenting 
in portions a gangrenous and pultaceous appearance ; ureters 
normal, kidneys much congested, especially in the pelvis of 
the left, and the results of peri-nephi'itis were shown in a 
number of small abscesses which smTOunded the right kid- 
ney, the capsule of which was thickened. 

The following history of the patient seen in the next ward 
affords an illustration of some of the vao:aries of cellulitis : 



CELLULITIS. 377 

Case 165. — Cellulitis of abdominal wall in a virgin, — 
Dr. Wicoll, House Physician. 

Fannie Brown, aged 18; Irish; servant; n:nniarried; 
began to menstrnate when thirteen years old, and has always 
been healthy and " regnlar " nntil four months ago, when 
she was taken with a severe pain in her bach (lumbar region), 
and with pain and soreness on the right side of her abdomen. 
She soon after this noticed a swelling in this region (abdo- 
men), which pained her very mnch when tonched, but other- 
wise gave her very little annoyance. When the swelling 
commenced she had a chill, followed by fever, and since the 
commencement of this illness she has not menstruated, has 
lost a great deal of flesh, and is feeble. She is now emacia- 
ted, with a feeble pulse, and anaemic. Digestive organs in 
good condition. There is a moderate uniform prominence 
in the abdominal wall on the right side of the linea alba, 
bounded below by Poupart's ligament, and above about an 
inch and a half below the floating ribs. Toward the median 
line it is limited by a well-defined margin, an inch external 
to the linea alba. On the right side it gradually disappeared, 
but may be said to be limited by a line drawn from the false 
ribs to an inch in front of the ant. sup. spin, process of the 
ilium. The swelling is exquisitely sensitive to the touch, 
and has a hard, woody feel. The fingers can pass under the 
margin near the linea alba, so as to show that the swelling is 
within the abdominal wall, and conjoined manipulation ex- 
cludes the sexual organs from any participation. Hence 
cellulitis of the abdominal wall was diagnosticated. April 
2, 1867. — The tincture of iodine was painted over the site of 
the swelling twice during every twenty-four hours. Under 
this and the internal use of the iodide of potassium the most 
marked and rapid improvement foKow&ST 

The cases of which the histories have just been given, 
and the cases of cellulitis in the post-puerperal state, which 



378 OBSTETRIC CLINIC. 

liave been sliown you in my service, iiave fortunately done 
well, but there is no such thing as the practice of medi- 
cine without the occasional observation of results which 
we regret to witness, and the case of ISTancy Hemy, be- 
fore you, offers an illustration both of the risks of cellulitis 
as a complication of uterine treatment, and of the develop- 
ment of suppuration in spite of our best efforts. It is, of 
course, possible that the cellulitis in the case of Nancy 
might have developed without other apparent cause than 
in the case of Catharine Hanna, but we must never shrink 
from applying the jpost and jpTOj)ter hoc to our reverses, al- 
though we ought most sedulously to criticise them in om- 
successes. ISTo habit tends more surely to the improvement 
of the physician's knowledge and methods of practice, what- 
ever effect it may have on the serenity of his mind. 

Before recommending the use of the sponge-tents in the 
case of Nancy Hemy, I hesitated for some days, for although 
the physical signs indicated their use, both as a means of re- 
ducing the hypertrophy, of restraining the flow, and possibly 
of recognizing some small fibroid or other cause for the 
menorrhagia; still, the bad constitution of the patient, and 
the hospital atmosphere, suggested a clinical reluctance to 
active treatment in this case, and has often deterred me from 
its use in others. But the improvement which followed the 
first tents encouraged the resort to others. 

Case 166. — Pelvic cellulitis and suppuration following 
sponge-tents. — Dr. Nicoll^ House Physician. 

Nancy A. Henry, aged 35 ; United States ; widow ; a 
nurse ; began to menstruate when sixteen years old, has had 
two children, the last was born at seven months, in 1850, 
the labor having been brought on by fright, and since then 
she has been an invalid. She was troubled with menorrhagia 
for two years, and since then has always been subject to pro- 
fuse flow. She is pale, care-worn, and somewhat emaciated. 



CELLULITIS. 379 

The whole uterus is enlarged, cervix hypertrophied, os patu- 
lous. The sound passes three and three-quarter inches. Dr. 
Elliot recommended the use of sponge-tents, and they were 
introduced by Dr. Mcoll from time to time with care, and 
the woman was relieved by them. After this treatment had 
been continued from time to time for a month, she suddenly 
began to complain of pain in the left side of the abdomen, 
low down, and of pain in passing water. Treatment was 
stopped and appropriate sedative measures used. The pains 
continued, some febrile action manifested itself, and on 
vaginal examination the evidences of peri-metritis (cellulitis) 
were found. The uterus was immovable, and the tissues 
surrounding the cervix were very much indurated. Cotton 
and oiled silk were ordered to the abdomen, opiate vaginal 
suppositories for the relief of pain, and hot- water vaginal in- 
jections, with extra diet, and the iodide of potassium. May 
15th. — It has been evident for some days that suppuration 
was advancing, and to-day the pus has been freely discharged 
per vaginam ; the opening is distinctly recognizable to the 
touch in the fornix of the vagina. Pus continued to be dis- 
charged at intervals until the 23d of May. 

Should pelvic abscesses from cellulitis always he ojpened 
2?romj[)tly f — A clinical point of interest, to which the atten- 
tion of the class was called at the time for its decision in this 
case, has been the question whether an incision should have 
been made when the pus was recognized, or whether we 
should have allowed it to find its own way out, as we decided 
to do. In the present case I decided to let the matter escape 
through its own channel, though the danger of its rupturing 
into the peritoneal cavity was pointed out in my clinical re- 
marks at the time. The progress of the case has, at least, 
been as satisfactory as it could have been if an incision had 
been made ; and therefore the result may justify the prac- 
tice. For my own part, nowadays, as a rule, I rarely 
find it necessary to open mammary abscesses, abscesses in 



380 OBSTETRIC CLmiC. 

tonsillitis, and in cellulitis. Mammary abscesses must of 
course be opened, if their anatomical site, or tbe great vital 
tenacity of the skin, or very severe pain from tension, demand 
the operation; and abscesses in the deeper tissues of the 
throat may imperatively demand the knife ; vf^hile if the pel- 
vic abscess break into the peritoneal cavity one may vrell re- 
gret that the vaginal or rectal wall had not been previously 
punctured. 

Case 167. — Pelvic abscess ojpening into the peritoneal cavity. 

It occurred to me in the autumn of 1861 to lecture clini- 
cally in this hospital on a case of pelvic cellulitis in the post- 
puerperal state, and to decide to leave the pus to find its way 
out when it should form, as it then threatened to do. In a 
few days afterward the patient was attacked by peritonitis, 
from the breaking of the abscess into the peritoneal cavity, 
and this accident was verified by the autopsy. I have been 
informed that one other case of the same character happened 
in this hospital. 

I^ow, such an untoward result would seem to demand im- 
peratively that the risk of so fatal an accident should always 
be obviated by a resort to timely evacuation of the pus ; and 
such must be the law inevitably, if this sad contingency be 
not demonstrated to be a very striking exception to the rule. 
That such has been the case in my experience in a field sin- 
gularly fruitful in pelvic cellulitis, I can unhesitatingly aver, 
and it ' is not probable that statistics will show other results. 
And, therefore, it is my belief that it has been better to ac- 
cept these rare contingencies, rather than to inculcate the 
practice of precipitate incisions for the escape of pus from the 
pelvic organs. The difficulties that attend the recognition of 
pus in these regions, and the vascularity of the tissues, 
should be remembered in connection with the fact that the 
accumulation will generally be discharged in a safe manner 
through a well-channelled outlet. While I believe that this 



CELLULITIS. 381 

expectant plan is best adapted, as a rule, to secure good re- 
sults in a large number of cases, I yet regard the decision in 
each as elective ; and if it be decided to make an opening, I 
would only nrge the practice which I always follow, viz., the 
introduction of an exploring needle before making any free 
or deep incision. 

Pelvic Jistidce. — One powerful argument in favor of timely 
evacuation of pus by the knife, might be found in the likeli- 
hood that snch a practice might diminish risks of permanent 
fistulous tracks. Patients have come nnder my care with 
these openings high np into the rectum, or into the vagina, 
depending on the formation of matter in the neighborhood 
of the broad ligaments, and giving rise to great inconve- 
nience from constant or intermitting discharges, with consti- 
tutional disturbances in direct relation to the frequency and 
degree of the inflammatory symptoms. 

Many of these women are made Avi'etched in mind and 
body by these disturbances, and yet these fistulse can never 
be treated by incision, and are often so rebellious to injections 
that these must frequently be abandoned, and we are driven 
to rely solely on time and roborant treatment. My expe- 
rience has taught me that it is best to commence the injec- 
tion of these fistulse with tepid water in very small quantity, 
and with every precaution, lest we might do more harm than 
good. In the very case of ISTancy Henry, such a fistula may 
follow the suppuration. Still it is fair to state my personal 
conviction that these permanent fistulse are quite infrequent, 
and that while they mnst be accepted, they need not be an- 
ticipated. In one autopsy where no complaint had been 
made of these troubles, and the patient had died from other 
causes, I saw an old fistula extending from the right ovary 
way across the pelvis and opening into the rectum. 

If we kept our minds fixed on the exceptions, rather than 
on the probabilities, in the practice of medicine, we would 
have even more anxious and harassing lives than now fall 
to our lot, and we would not be as good practitioners. 



382 OBSTETEIC CLINIC. 

In the same ward with, these patients is another with the 
following history, which illustrates the favorable results of a 
different treatment for uterine conditions not altogether dis- 
similar. 

Case 168. — Abortion i metritis ; hy^ertrojphy of uterus. 
— Dr. jSficollj House Physician. 

M- S , aged 25 ; Irish ; domestic ; married. Be- 
gan to menstruate at the age of fourteen ; and has been 
regular excepting when pregnant. She has been pregnant 
twice, and gave birth to the first child at term. Three years 
ago when lifting a very heavy mattress she experienced a 
sharp and violent pain in the lower part of the abdomen, and 
began to bleed from the vagina. She was confined to bed 
for six weeks by this trouble and was told by her physician 
that she had prolapsus uteri. Since then, after any exertion, 
she has had leucorrhoea. She became pregnant for the sec- 
ond time in June, 1866, and illegitimately. When two months 
and a half gone^ she states that she paid a physician in a 
neighboring city five dollars for procuring an abortion by the 
use of instruments. Great loss of blood followed, and since 
then she has been subject to profuse hemorrhages. When 
admitted to the hospital, in April, 186Y, she was very pale 
and anaemic, and weakened by the loss of blood. She com- 
plained of constant and severe pain in the hypogastrium. 
The uterus was found to be considerably enlarged, and the 
cervix uteri seen to be lacerated transversely. The surfaces 
of the laceration were ulcerated. She was placed under a 
tonic course of treatment, with rest in bed ; and the cervix 
was touched with a drachm of tannin to the ounce of glycer- 
ine once in the twenty-four hours. In ten days the ulcera- 
tion was cured, and then a free application of the vesicating 
collodion was made to the cervix, and repeated in a couple 
of days. After the second application, the discharge was 
very free from the blistered surface. After the lapse of a 



ABOKTION. 383 

week tins was reapplied and for a foiirtli time seven days 
later. Meanwhile a large blister liad been applied over the 
hypogastriuiQ. All of these applications were followed by 
marked relief and benefit, and the patient was discharged at 
her own request on the 29th of May, in a satisfactory con- 
dition. 

Bemarlcs. — In this case the benefits from treatment were 
more marked and immediate than can always be attained ; 
and you have seen that the temperament of the patient is of 
that complaining and nervous character, that assurances of 
great improvement may be accepted with a confidence not as 
safely accorded to complaint. 

The jpractice of abortion in this country. — ^We have no 
reason to doubt the history which she gives us regarding the 
abortion which was procm*ed upon her at her own instance. 
The public prints, the JN'ational Medical Association, and 
the profession, have di^avni the attention of the community to 
the melancholy frequency and comparative impunity which 
marks the practice of the abortionists. Still the daily press 
publishes the advertisements of these people in such thinly- 
veiled language that the purport cannot be mistaken ; while 
pregnant women are tempted to solicit such treatment by 
the necessity for concealing their shame, from ignorance of 
the vitality of the foetus, and reluctance to incur the cares, 
risks, and responsibilities of maternity. Let us hope that 
the movement so prominently advocated by Dr. Storer may 
result at least in arresting the horror of this practice in many 
families, by removing the errors and misconceptions regard- 
ing the value of foetal life. 

Necessity for more hosjpitals. — For such cases there can 
be no other repressive measures than those of punishment, 
except in the multiplication of lying-in asylums, and such 
noble enterprises as that attached to the N^ursery and Child's 
Hospital of this city, where unfortunate women can be cared 



,/' 



384: OBSTETRIC CLINTC. 

for during tlieir confinement, wliile their names and history 
are concealed, and where foundlings are received. 

The fact should be known far and wide, that in the city 
of ]^ew York ladies of the first social position not only give 
to this entei-prise their money and then- counsels, but grace 
it with their personal supervision. 

Tojncal abstraction of Uood from the uterus. — In the 
case just narrated, the apphcation of leeches to the uterus or 
the topical abstraction of blood might have been indicated, 
were it not for the fact that the patient had abeady lost so 
much, and was so anaemic. Another patient in the same 
ward has just told you of the relief which she has experienced 
from the use of the uterine scarificator, and there is no doubt 
of the benefit to be derived from the judicious use of this 
method of treatment in appropriate and sthenic cases. 

"We can take blood from the uterus by leeches, and by 
scarifications, which may be superficial or more penetrating ; 
and we can take it from the lining membrane by Simpson's 
ingeniously-contrived instrument for cupping, and Storer's 
concealed knife. As all the " uterine cases " contain a scarifi- 
cator, it is most probable that this method is the one in most 
general use. The application of leeches requires a certain 
skill, and demands certain precau.tions, nor can they be used 
mthout delay and the liabihty to fatigue the patient. Still, 
in appropriate cases, where there is a moderate amount of 
increased uterine sensibility — with soreness, fulness, and 
weight — in patients of a full habit, and those especially prone 
to recm-ring congestions, they are often so comforting, that 
many of my patients, having experienced relief on one or 
more occasions, have often sent for the leeches and prescribed 
them for themselves. They are especially beneficial in such 
cases occurring in hearty, full-blooded women, with scanty 
menstrual flow, who are approaching the grand climacteric, 
and render their journey more safe by occasionally opening 
the safety-valves. 



METEITIS. 385 

TTliile, liowever, these remarks are clinically accurate, 
tliere is no doubt whatever in my mind that practitioners 
and patients may allow this train of reasoning to lead them 
to the unnecessary and even injudicious routine use of topi- 
cal uterine depletion. 

In my own practice these measures were resorted to by 
me more frequently in former years than they are at present ; 
and while I recognize fully the temptations to the treat- 
ment, and the benefits which I have signalized, my advice 
now would rather be, in cases which admitted of delay, to 
reserve depletion for those in which other measures had 
failed. 

We all know what is meant by chronic metritis, although 
we admit that discordant and imperfectly appreciated condi- 
tions are embraced under the name ; and, for my own part, 
my tendencies are to the use of tonic and constitutional treat- 
ment, with fresh air and well-directed exercise, and visits to 
such mineral springs as meet special indications ; to the free 
use of local sedatives, including large injections of hot water, 
rendered still more sedative by stramonium, or by other 
agents, as hip-baths and anodyne suppositories made with the 
butter of cocoa, the value of which ingredient has only been 
recently appreciated abroad ; to the removal of pressure from 
the intestines in stout patients by an abdominal bandage 
which shall lift the intestines, and not crowd them into the 
pelvis, and in certain cases by intra- vaginal pessaries ; to the 
removal of exciting causes ; to the soothing of localized in- 
flammatory tracts of mucous membranes by topical applica- 
tions, remembering always the risks from developing peri- 
metritis and pelvic peritonitis, or aggravating these compli- 
cations when they exist ; and to the application of such 
agents as have so benefited the patient, M. S. before you. 

"We must struggle against a tendency to run in the grooves 
of routine in om^ practice as physicians; it is so strong a 
temptation to the busy man who has reason to believe him- 
self as successful as his neighbors ; it saves so much trouble, 
25 



386 OBSTETEIC CLINIC. 

and so mucli of that mental wear and tear whicli oppress 
US all ; and the motion is so pleasant and insidious that one 
maj well be pardoned for a reluctance to struggle against its 
influences. 

It is probable that a yerj large number of the leeches 
applied, or intended to be applied to the cervix uteri, in 
reality take hold of the vagina ; and the worst bleeding that 
has come under mj observation in these cases, has occurred 
under these circumstances. It is of coiu^se readily controlled 
by cold or astringents, but the accident may have made the 
difference between the beneficial and the prejudicial effects 
of leeches. Be sure to tampon a patulous, cervix uteri before 
applying leeches, lest the very painful and distressing uterine 
colics which follow the entrance of a leech into the cavity 
make you regret the neglect. Be sure to count the leeches 
after the application has been made, that all present may 
be relieved from anxiety regarding the whereabouts of a 



Beware of pregnancy. — Be sm-e, in all topical applica- 
tions to an hypertrophied uterus — whether of the sound, the 
cautery, the blister, the leech, the caustic, the ointment, or 
the liquid — that the hypertrophy is not that of physiological 
pregnancy. Patient and physician may be honestly unsus- 
picious, and ignorant of the situation. Let the question of 
pregnancy always be present to yom^ minds. In cases of 
doubt, abstain from local treatment and from frequent ex- 
aminations. 



CHAPTER XIY. 



CEETATN" COXDITIONS OF THE BLADDER IN" WOMEN. 

The clinical necessity for ascertaining the amount of urine which women may 
pass under certain conditions. — Case: Eetention of menses by an imper- 
forate hymen ; operation. — Case : Dysuria from aphthous ulceration. — Case : 
Retroversion of impregnated uterus ; great accumulation of urine ; success- 
ful reposition and recovery. — Case : "Unilocular ovarian cyst in the recto- 
vaginal cul-de-sac, complicating parturition and the cause of death. — Case: 
Retroversion of impregnated uterus. — Case: Retroversion of impregnated 
uterus. — Choice of catheter. 

The clinical necessity for ascertaining the amount of 
urine which women joass under certain conditions. — From 
motives of modesty, and certain conditions of disease, women 
are peculiarly liable to retain their urine from choice and 
fi'om necessity in circumstances which do not afiect the other 
sex. Many cases in this work demonstrate the clinical impor- 
tance of appreciating the amount of urine passed by a preg- 
nant woman with albuminuria. ITos. 94 and 99 illustrate 
the result of ulcerative perforation of the bladder, while in 
Case No. 164 peri -nephritis and cystitis were the causes of 
retentiou. 

The following cases show the results of other influences, 
which do not affect the male. 

Case 169. — Retention of menses hy an imperforate 
hymen I operation, — P. C, Barker^ M, D., Souse Physi- 
cian, 

Alice, set. 17 ; born in Connecticut ; of delicate organiza- 



888 OBSTETEIO CLINIC. 

tion ; admitted to Belle vue June 23, 1860. She never en- 
joyed good health, from her infancy. In July, 1859, she 
experienced her first menstrual effort, which was not attended 
by any discharge. The molimen has regularly appeared 
since, the flow never. The mother, and the physicians to 
whom she applied at various times, attributed the absence 
of discharge to the general condition of the girl's health, and 
administered iron and emenagogues of various kinds. These 
only served to increase her sufferings. After a time the 
periods were marked by bearing-down pains like those of 
labor, which progressively increased in severity, and awak- 
ened more and more constitutional excitement. On Thurs- 
day, the 21st of June, the last effort began. She suffered 
more pain in the back, and the bearing-down pains were 
more than usually severe, keeping her awake all night. She 
passed water with some difficulty, and obtained a movement 
from her bowels. On Friday a physician was called, who 
prescribed something to quiet her sufferings, and left. Short 
relief followed. Another sleepless night, no water passed. 
Saturday morning. — Two physicians called, who ordered salts 
and senna, and advised that she should be sent to the hospi- 
tal. She was admitted in the evening (23d), having neither 
had a movement from her bowels nor passed a drop of water 
for forty-eight hours. 

Synvptoms on admission. — ^Yery restless, anxious, tossing 
and moaning with pain. Pulse 112, tongue slightly coated. 
Palpation discloses an abdominal tumor, hard and tense on 
pressure, and perfectly dull on percussion. Catheter intro- 
duced with little trouble, and fifty-three ounces of bloody 
urine drawn, after which the tumor could no longer be felt. 
She immediately fell asleep, and on awakening in half an hour 
had a very free discharge from the bowels. The external 
organs of generation were not deformed, but the vagina was 
perfectly occluded by an imperforate hymen, rendering the 
introduction of the finest probe impossible. The finger in 
the rectum discovered that the vagina was so completely 



IMPEEFOEATE HYMEN^. 389 

distended that no fluctuation could be detected. Tlie accu- 
mulation seemed to fill the pelvic cavity. 12 p. m. — Sleeping 
quietly. 21^/^, 9 p.m. — Some pain in abdomen, relieved by 
catheterization. Thirty-three ounces of urine drawn off, which 
contained both pus and blood. Dr. Elliot sent for, who de- 
cided on operating, after a careful examination; and in anti- 
cipation of the great danger to the patient, determined to 
make a very small incision, and allow the accumulation to 
drain away gradually. Choosing a pair of sharp-pointed 
scissors (by the advice of Dr. Gouley), he began to cut in the 
direction of the com.'se of the vagina. The membrane was 
nearly half an inch in thickness. About four ounces of a 
tarry-looking fluid were allowed to trickle through a very 
small opening, when the patient was replaced in bed, and 
ordered Magendie's solution four drops, and oiled silk to ab- 
domen. The administration of chloroform having produced 
hysterical symptoms, it was discontinued before the opera- 
tion was commenced. 6 p. m. — Pulse 140 ; sol. morph. sulph. 
(IVIagendie) gtt. vij. 9 p. m. — Pulse 130 ; sol. morph. sulph. 
(Magendie) gtt. iv. 25z5A, 8 a. m. — A large quantity of men- 
strual fluid has drained away during the night ; bladder had 
subsequently partially relieved itself; 3 vj of urine drawn 
by catheter ; pulse 120 ; feels better ; has passed a comforta- 
ble night ; still has a little pain ; sol. morph. gtt. iy. 12 m. 
— Pulse 112; sleeps most of the time; vagina dilated by 
bougie. 6 p. m. — Pulse 120 ; gtt. iv. 11 p. m. — Pulse 120 ; 
gtt. V. 26^A, 8 A.M. — Pulse 120; has slept most of the 
night ; i XV of urine drawn with catheter ; discharge still 
continues. 3 p.m. — Injected warm water into vagina, to 
dilute the discharge, which still pours out. JSTearly a quart 
in all must have escaped. Some pain ; sol. morph. gtt. iv ; 
larger bougie introduced. 6 p. m. — Pulse 124 ; gtt. vj ; 
catheter regularly passed. 27th, 8 a. m. — ^Pain in abdomen, 
with nausea ; some tympanites ; gtt. vj ; appetite, which has 
been very good, now failing. 12 m. — 'No pain; respiration 
scarcely affected ; gtt. iv. S p. m. — Free movement from 



890 OBSTETEIC CLINIC. 

bowels, after wliicli tympanites less marked ; some yomiting, 
but notbing of green color ; pnlse 104 ; gtt. TJ. 10 p. m. — 
Pulse 128 ; gtt. rj. 2^th^ 8 a. m. — IsTo pain, slept very well ; 
passed water tbree times in tbe nigbt, still not all dis- 
cbarged ; menstrual fluid slowly coming away ; gtt. iv. 6 
p. M. — Has bad a movement from ber bowels ; vagina now 
admits index-finger ; a tumor detected in tbe left iliac region, 
cbaracter of wbicb is obscure ; no pain ; pulse 130. 10 p. m. 
— Pain, pulse 135 ; gtt. yj. 29^A, 8 a. m. — ^Passed ber water 
very well, but catbeter introduced to prevent an accumula- 
tion ; pulse 120 ; gtt. iv. 3 p. m. — Fluctuation detected in 
tbe tumor of left iliac region. 9 p. m. — ^Restless ; gtt. yj. 
30^A, 8 A. M. — Pulse 120 ; ratber weak ; vagina well dilated. 
6 p. M. — Yery little pain ; gtt. iv. 

July 1st, 8 A. M. — Comfortable, but quite weak ; bad a 
severe cbill during tbe nigbt, wbicb lasted for an bour ; so- 
lut. quinise sulpb. 3 ss ad 3 iv. | ss ter in die, beef-tea, eggs, 
etc. ; pulse 125. 2d. — Yaginal injection of a warm solution 
of tbe cblorinate of soda for foetor ; pulse 120. Sd. — Injec- 
tion repeated ; continues mucb tbe same ; gtt. iv. 6th. — 
'No discbarge from vagina ; fluctuation distinct in left iliac 
region; urine still contains blood; treatment continued, 
witb addition of brandy 3 ss every bour. 6th. — "No dis- 
cbarge from vagina ; comfortable. 9th. — Tbere bas-been no 
especial cbange. Lager beer was substituted for tbe brandy. 
Two severe cbills to-day, lasting an bour eacb ; bas been talk- 
ing of going out of late ; bas been up walking in tbe ward. 
10th. — Quinine as before ; pulse 125 ; some pain ; gtt. yj. 
12 M. — Feeling better, sbe sat up for some time to bave ber 
bed arranged, after wbicb diarrboea ; bas bad four evacua- 
tions since 8 a. m. ; ordered tr. op. campb. 3 i after eacb 
discbarge. 6 p. m. — 'No discbarge from bowels since 1 p. m. ; 
pulse 130, and quite feeble ; brandy | j and carbonate of 
ammonia gr. x every two bours. 12 m. — No pain ; bas bad 
two more discbarges from tbe bowels ; tr. op. campb. 3 ij ; 
brandy and ammonia as before. 11th. — ISTo furtber move- 



IMPEEFOEATE HYMEN, 391 

ment of the bowels ; pulse 132, yeiy feeble ; stimulants con- 
tinued. 10 A. M. — Sinking; pulse barely perceptible. 11 
A. M. — Died. 

Autopsy, — ^Permission obtained witb great difficulty, and 
only after a promise tbat notbing should be removed, and 
only tbe abdomen examined. IVeatlier warm. Bigor mortis 
not very marked. Body moderately well nourisbed. Ab- 
domen sligbtly tympanitic. On section no fluid escaped. 
Omentum firmly bound by adliesions in both iliac as well as 
in the supra-pubic regions. In tbe left iliac region, resting 
upon the peritoneal covering of the iliacus internus muscle, 
was a collection of pus, not exceeding a drachm in quantity, 
shut in by walls, composed of omentum and fibrin. The in- 
testinal serous coat was pohshed and smooth, and not covered 
with exudation, excepting a portion of the upper part of 
the ileum, and sigmoid flexure of the colon. The portion of 
the ileum referred to was adherent to the fundus of the blad- 
der, and presented perforations which corresponded with 
some of many small perforations which riddled the fundus of 
the bladder. The vesical mucous and muscular membranes 
were softened, and the color very deep. The viscus seemed 
to be undergoing disintegration. Eight kidney contracted 
and fatty ; pelvis and ureter greatly distended and contain- 
ing pus. Left kidney large and fatty; ureter and pelvis 
normal. The sigmoid flexure of the colon was bound down 
by adhesions, and presented a patch of about two inches in 
its long diameter where the tissues presented a gangrenous 
appearance and several perforations. The uterus measured 
about four inches in length, its os and cervix fully dilated. 
Os internum not, however, obliterated. Arbor vitse very dis- 
tinct. Uterine sinuses presented no abnormal appearances 
on section. Uterine orifices of Fallopian tubes not dilated. 
The left Fallopian tube, at about the distance of one inch 
from the uterus, terminated in a mass formed from the or- 
gans contained in the left broad ligament, but so transformed 
by disease as not to be separable in the limited time afforded 



392 OBSTETRIC CLrN"IC. 

bj the exigencies of the case. Right ovary the subject of 
unilocular cystic degeneration, the cyst being about an inch 
and a half in the long diameter. Other organs not examined 
for the reasons given. 

Remar'ks. — The extraordinary results of this post-mortem 
examination lend the deepest interest to this case, and make 
it, I believe, one of the most remarkable on record. It never 
occurred to me that the fluctuating tumor in the left iliac re- 
gion, detected on the 2Sth, was the product of the peritonitis, 
though I now believe it was due to pus enclosed by perito- 
neal adhesions. "Whether the diarrhoea was produced by the 
discharge of this pus into the colon may be believed, but 
cannot be positively predicated ; nor could we have antici- 
pated the perforations through the fundus of the bladder and 
the portion of ileum thereunto attached, unless, possibly, from 
much more thorough microscopic examinations of the urine 
than were made. "With such post-mortem evidences of peri- 
tonitis as we found, it is pretty certain that a high grade of 
general peritonitis must have yielded to the treatment em- 
ployed. Those reading the record of the case, however, can 
scarcely appreciate the comparatively satisfactory condition 
of the patient in all respects, except the urine, for some days 
before the tenth. She felt able and willing to leave the hos- 
pital, and her mother j)roposed to take her out. So much 
better had she progressed than was apprehended, both from 
the extreme danger which always attends these operations, 
and fr'om the other complications existing, that my very un- 
favorable prognosis was much modified ; and I was neither 
prepared for the sudden termination nor for some of the 
strange revelations of the autopsy. 

An important practical reflection in this case and many 
similar ones, is the neglect of proper vaginal examinations 
by the physicians who had seen her before her admission to 
the hospital. A number of instances have come under my 
observation, in which much mental unhappiness and physical 
suffering have been allowed to continue which could have 



DYSIIEIA. 393 

readily been relieved by intelligent examination ; and the 
converse of tlie proposition is equally true. 

Case 170. — Dysuria from aphthous ulceration. 

A lady from a neighboring city came under my care for 
great suffering in passing water ; the vulva was found to be 
much inflamed, the seat of aphthous ulceration, and sensitive 
beyond measm-e. She menstruated, but informed me that 
although married for some years, she never had complete con- 
nection with her husband, on account of a " deformity ;" that 
she had consulted a physician shortly after her marriage, 
who told her that she was deformed, and that there was a 
" bony obstruction." I took Dr. E. Lambert, then one of the 
house physicians in Bellevue, to the case, and he kept her 
imder the influence of chloroform, while I introduced a full- 
sized speculum, and disclosed a well-formed vagina and 
uterus. 

Retroversion of the uterus in jpregnancy, — The following 
cases of retroversion of the impregnated uterus illustrate 
clinical conditions which urgently demand early recognition, 
and thorough treatment. 

Case 171. — Retroversion of im/pregnated uterus; great 
accumulation of urine / successful reposition and recovery. — 
Dr. Mola^ House Physician. 

Isabella Armstrong, aged 25, was admitted into Bellevue 
Hospital on the 27th of October, 1863. She was a healthy 
woman, and stated that her health had always been good. 
Has had two children, both now living and in good health. 
After the second confinement she suffered from falling of the 
womb, which came down near the vulva, but was never 
treated for this trouble. Four months ago her menses stop- 
ped. She suffered from morning-sickness and the other evi- 
dences of pregnancy as in her previous gestations, and now 
has milk in the right breast. On the 15th of October she 



394: OBSTETEIC CLINIC. 

went to a funeral, and on getting out of the carriage slipped 
and struck her abdomen against a gravestone. She was 
much prostrated by the shock, and had to be assisted home 
in the carriage by a friend. She has since been confined for 
most of the time to the recumbent posture before entering 
the hospital. I saw her in the afternoon of the 28th, and 
recognized a large tumor in the recto- vaginal cul-de-sac ; the 
OS uteri could be reached with difficulty through the vagina, 
narrowed by the projection forward of the posterior vaginal 
wall, but could be recognized on the level with the upper 
part of the symphysis pubis. The patient had walked the 
whole length of the ward to the examining-bed ; she pre- 
sented no symptoms calling for immediate relief; she had no 
evidences of inflammatory action. Pregnancy was evident 
from her history and symptoms, though neither foetal heart 
nor foetal movements were recognizable. Some cathartic 
medicine, which had been given on the previous evening by 
Dr. Mola, had not operated, and I ordered castor-oil to be 
given, preparatory to a thorough examination on the morrow. 

October '^^th. — ^Bowels have been freely moved. Her 
condition as before. She again walked across the ward to 
the examining-bed. But now, before proceeding to the 
thorough examination of the case, I inquired about the blad- 
der, when she declared that she had not passed water for a 
week, though, she stated, some had dribbled away at times 
when she walked. This was the first allusion made by her 
to the state of her bladder. A catheter was then introduced 
and one hundred and forty-four ounces of urine were drawn 
off in the presence of my colleague. Prof Barker, and other 
gentlemen. This urine was of natural color, good specific 
gravity, of healthy odor and reaction, and free from albumen. 
The abdomen diminished in size, and the diagnosis of a re- 
troverted pregnant uterus could be clearly made out. 

She was then brought at once under the influence of. 
chloroform by one of the house physicians, while another, 
standing on.the bed, raised her hips high in the air, so that 



EETEOTEESIOX OF IMPEEGNATED UTEEUS. 395 

the abdomen looked downward toward tlie bed. I then 
introduced tlie fingers of tlie riglit hand in the vagina, and 
pressing the fiindns of tlie nterns througli the posterior vaginal 
wall, succeeded in an instant in passing it along the curve 
of the sacriun and leaving it well anteverted. In so doing 
I distinctly felt the ballottement of the foetus. 

After the efiects of the chloroform had passed, she said 
that she felt perfectly well and comfortable. All traces of 
the tiunor, which had so greatly distended the posterior cul- 
de-sac, and which had been so readily grasped between the 
fingers of one hand in the vagina and one in the vulva, had 
disappeared, while an ample vagina and pelvis could be rec- 
ognized. 

The m*ine drawn from this patient and the patient were 
shown at my chnical lectm-e. She never had an unfavorable 
symptom afterward. She never once needed the introduc- 
tion of a catheter, nor showed any further tendency to uterine 
displacement or hemorrhage ; and after ten days of close ob- 
servation she left the hospital, somewhat wearied with what 
she had considered to be unnecessary care. 

The British and Foreign Medico- Chirurgical Review for 
April, 1864, gives the history of the accumulation of fourteen 
English pints of urine in the bladder of a man, aged 63. 

Yide " Transactions of the Pathological Society " of 
London, vol. xv., p. 136, for four cases of exfoliation of the 
mucous membrane of the bladder. Also " Transactions of 
the London Obstetrical Society," vol. iv., p. 13. 

The following case is interesting in its relations to the 
differential diagnosis of such tumors as those just considered, 
as well as in its other obstetric relations : 

Case 172. — ZfniloGular ovariam, cyst in recto-vaginal cul- 
de-sac complicating j)arturition,and the cause of death. — Drs. 
Fernandez and De Bosset, House Physicians, 

Jennie Syzer, aged 24, was carried into Bellevue Hospi- 
tal, January 22, 1861, at 6 p. m., in a very feeble condition. 



396 OBSTETEIC CLIXEC. 

Eespii-ation hurned; pulse 120, and slender; skin moist; 
bodv emaciated, sallow, anEemic-looking. Abdomen slightly 
tympanitic, locliial discharge scanty, milk secreted in small 
quantity, eight ounces of non-albuminous ui*ine drawn with 
a catheter. Ordered Dover's powder, and a warm anodyne 
poultice to the Tulva, wliich was swollen and painful. It 
appeared from the patient's account that she had been de- 
livered instrumentally by a midwife of a dead child about 
a month before. 

Jaiviary 2Sd. — Symptoms of peritonitis better marked. 
Blister to abdomen; moi'phine and veratrum viride, with 
beef-tea. In the evening large clots of blood came from the 
vagina, with much hemorrhage, which yielded to ice, ergot, 
and the tampon; brandy fr-eely given. 24:th. — Pulse 148. 
Tampon removed ; no hemorrhage ; ergot and brandy with 
an enema, as the rectum was fall of faeces. On visiting the 
patient this day, and hearing the history of the hemorrhage, 
I dictated the following memoranda. I had made no vaginal 
examination on the preceding day, as the symptoms of peri- 
tonitis then overshadowed all others : 

Posterior wall of vas'ina buloino; forward so as to make 
vaginal examination with the finger difficult. Os uteri not 
readily discernible to the touch, though a flattened opening 
exists above the top of the symphysis pubis, which could not 
be thoroughly explored. Examination through the rectum 
shows that the tumor felt thi'ough the posterior vaginal wall 
impinges on the calibre of the rectum, and can be readily 
grasped between one finger in the vagina and one in the 
rectum. There is a feeling communicated to the finger in 
portions of the tumor as though its contents were fluid. The 
hand laid upon the supra-pubic region recognizes a globular 
tumor, and sudden pressm-e from within the rectum com- 
municates an impulse to this tumor, not a sense of fluctuation, 
but as though they formed part of one and the same tumor. 
The patient's condition being one of great exhaustion, the 
moderate use of opium and thorough support were directed. 



OYAKIAN CYST. 397 

2Dth. — General condition so far improved as to allow ns 
to place her on her hands and knees, and in snch other posi- 
tions as to make as thorongh examination as the very con- 
tracted vagina wonld permit — three fingers could be intro- 
duced. ]l^o OS uteri could be reached. It seemed as though 
there were partial occlusion of the upper part of the vagina, 
and not unlike a cul-de-sac. JSTo result obtained with a 
uterine sound. Eectum bougie readily introduced. Slight 
pulsation detected within the vagina. 27th. — Patient's con- 
dition has been about the same. Pulse ranges from 120 to 
liO. Slight bloody and foetid discharge from the vagina. 
Sims's speculum shows the color of the vagina to be natural. 
I then introduced an exploring-needle through the posterior 
wall, and pus escaped, when I enlarged the incision suffi- 
ciently to admit a uterine sound readily, when thin sanious 
pus flowed freely. Brandy increased in quantity, and car- 
bonate of ammonia given. 28^^. — Considerable vomiting, 
not repeated. With Sims's speculum and gentle pressure a 
quantity of the sanious pus discharged through the incision. 
Quinine. 29th. — Passed water herself for the first time since 
admission. Incision enlarged, and a quantity of pus evacu- 
ated, which ran steadily for six hours, smelling very like 
asafoetida. While the pus was flowing, my hand placed 
over the supra-pubic globular tumor suddenly mapped out 
the uterus in its totality, not as though rising from a deflected 
position, but as if suddenly standing out in relief against 
a tumor placed posteriorly. Length normal. Os uteri to be 
reached an inch and a half above the pubes. 

February Uh. — The discharge has steadily continued, 
with the same odor, increasing in amount when the bowels 
— which were always regular — were moved. The strength 
has been steadily failing. Mind weakened. Died this after- 
noon. 

Autopsy twenty-one and a half hours after death. — In the 
presence of Drs. Taylor and Barker, and the house-staff. 
Weather cold. Pigor mortis well marked. Body emaciated. 



398 OBSTETEIO CLINIC. 

Abdomen not swollen ; opened by a crucial incision ; no 
fluid nor gas escaped. Evidences of peritonitis confined to the 
hypogastric and iliac regions. Adhesions of a firm charac- 
ter. Uterus in its normal axis, perfectly involuted, rises 
above the pubes. Left ovary, somewhat enlarged, rests upon 
the left side of the fundus uteri. Recto-vaginal cul-de-sac 
obscured by adhesions on a level with the brim of the pelvis. 
Horizontal and descending rami of the pubes sawn through 
and the bone removed. During this procedure pus escaped 
freely from the incision in the posterior vaginal wall. Blad- 
der presenting no appearances of interest ; dissected from the 
vaginal wall. Incision through the anterior vaginal wall 
prolonged through the uterus. Os uteri shown to have been 
perfectly dilated, and almost entirely obliterated, except at 
two points where the lips were thickened, and projected from 
the vaginal wall. Eecto-vaginal cul-de-sac occupied by a 
tumor, into which a sound could be carried through the in- 
cision in the posterior vaginal wall described in the history 
of the case. This tumor was ovarian, unilocular, containing 
pus, and a mass, about the size of a small orange, of fatty 
matter, hair, and a part of a maxillary bone, with one in- 
cisor and two bicuspid teeth. Liver and stomach healthy. 
Kidneys apparently fatty. Heart of normal size ; valves 
healthy — pericardium universally adherent. Lungs healthy. 
Brain not examined. These specimens were shown to the 
Pathological Society, and were preserved by L)r. Teats 
in the museum of Bellevue Hospital. He also found, in 
preparing the specimens, an opening in the upper part of the 
cyst evidently made by ulceration, the existence of which 
had not been appreciated before. 

Case 173. — Retroversion of impregnated uterus. 

Dr. Young asked me to visit Mrs. on the 14th of 

August, 1862, who had come to the city about two days 
before, suffering from dysuria, from which she had been com- 



EETEOYEESION OF IMPEEGNATED UTEEIJS. 

plaining about two weeks. She had been treated in a neigh- 
boring city, and had once had her urine drawn with a catheter, 
though no thorough vaginal exploration seemed to have 
been made. On the morning in which I saw her, Dr. 
Young had yisited her and found her unconscious, and evi- 
dently in an alarming condition. He had drawn off two- 
thirds of a large chamber-potful of clear urine with a catheter, 
and had recognized a retroverted uterus. He had been 
obliged to give chloroform to introduce the catheter. I found 
her unconscious, with a very bad facies, eyes like those of 
the dying, and recognizing nothing ; slight froth on the lips ; 
pulse very rapid and feeble ; skin neither cold nor warm ; 
not perspiring; respiration hm-ried. She tossed, moaned, 
threw herself on her elbows and knees ; frequently rolled in 
a rapid manner to the edge of the bed, as though desirous 
of throwing herself on the floor, and necessitating the con- 
stant presence of some one to restrain her. 'No paralysis ; 
no special tendency to 'roll in the same direction. Uncon- 
scious, evidently, but not raving. On examination I found 
the uterus entirely retroverted, the os on a level with the 
upper rim of the symphysis, the fundus down to the sacro- 
coccygeal articulation. Os sufficiently open to admit the 
finger. The uterus seemed about three months impregnated. 
To effect the reduction, we put her on her hands and knees, 
holding up the hips, as it was necessary to give her an anses- 
thetic (chloroform used) to quiet her. Pressure on the poste- 
rior vaginal wall caused half a tumblerful of bloody and very 
offensive urine to come away. Continuing the manoeuvre, I 
was enabled to push up the fundus uteri ; and then, by intro- 
ducing two fingers within the rectum, to continue pushing it 
up until it cleared the promontory. But the abdominal 
straining would force it down again. The vagina was short, 
and the cul-de-sac very deep. Satisfied that the uterus could 
not then be permanently replaced, I desisted. JSTot altogether 
liking the respiration, we gave a prompt trial of Marshall 
Hall's method, and she soon breathed as well as ever ; con- 



400 OBSTETEIC CLmiC. 

sciousness as before. Withont an ansestlietic no satisfactory 
uterine manipulations conld have been made. Believing that 
the case must terminate fatally, and as she conld scarcely 
swallow, we agreed that the colpenrynter should be used to 
cushion and replace the uterus, that the bladder should be 
kept emptied, and that she should be nourished by enemata. 
In five hours we met again. She was quieter, and sitting 
up, but if possible looked worse. Bladder nearly to the um- 
bilicus. Half a chamber-potful of bloody and very offensive 
urine drawn. Advised recumbent posture. Ihth. — Contin- 
ues to sink. Henal secretion copious, and drawn with cathe- 
ter. Some sent to Dr. "W". H. Draper for examination did not 
reach him. The uterus has never fallen back as low as it 
was, and is movable. Sank steadily, and died during the 
night. IsTo autopsy permitted. 

Case 174. — Retroversion of impregnated uterus. — Dr, 
H, Lyle Smithy House Physician^ in charge, 

B C ; Irish ; married \ aged 40 ; admitted to 

Bellevue October 9, 1865, for retention of urine. Short, 
sparely built. Has always been regular and temperate in 
her habits, and has never suffered from any serious illness. 
Is the mother of five children, all living. Labors natu- 
ral. Last unwell 1st of June. The stoppage attributed 
to cold ; has never supposed herself pregnant. Five weeks 
ago the urine "stopped." Before this time she had been 
obliged to pass it frequently day and night. The stoppage 
was accompanied by great pain and "bearing down." After 
suffering two hours, she was relieved by a catheter. Until 
the 4th of October she was able to void a little at a time, 
when she was totally unable to pass any, and the catheter 
was used twice a day. Yaginal examination detected the 
cervix uteri tilted up toward the pubes, and pressing upon 
the urethra. A large, firm, rounded tumor in the posterior 
vaginal cul-de-sac, not movable, and seemingly wedged in 



CHOICE OF CATHETER. 401 

the pelvic brim. It was continuous witb. the uterine neck, 
better appreciable through the rectum, and not appreciable 
through the abdomen. Areola moderately discolored. Pa- 
pillae not deyeloped. Retroversion of impregnated uterus 
diagnosticated. One and a half pints of urine drawn by the 
catheter. Several fingers being then introduced in the va- 
gina, while the woman was on her back, by slight pushing 
and tilting the uterus returned to its place and could be 
recognized above the pubes. She subsequently passed her 
urine freely and easily, and has done so without the least 
trouble until to-day (October 14:th), the day of her discharge. 
Her bowels have also moved regularly, which they did not 
do before admission. 'No special cause can be assigned for 
the retroversion. 

Choice of catheter. — In the parturient woman the flexible 
male catheter should always be used. It would be better for 
women if the ordinary silver female catheter had never been 
devised. It is surprising to see the distance to which the 
elastic male catheter may have to be introduced in some 
cases before any urine can be obtained. The bladder may 
be pushed up, the urethra stretched, by the foetal head, and I 
have met with cases where the water could not be drawn until 
delivery had been effected. When the practitioner fails to 
procure any urine with the catheter during the progress of 
the labor, he should be sm^e at least that a long, flexible cath- 
eter has been fully introduced within the bladder. The im- 
portance of deciding this fact unequivocally is of the utmost 
value in its relations to diagnosis and prognosis in vesical 
and renal complications. 



26 



CHAPTER XY. 

DA]SrGEES FEOM COMPEESSIOK OF THE FUOTS. 

Case: Prolapse of funis. — Case: Pelvic presentation and arrest of head in the 
pelvis; compression of cord. — Case: Compression of cord in a cephalic 
presentation. — Case: Transverse position of head; cord around the neck of 
a still-born child. — ^Dangers to the child from compression of the funis. — 
Cord around neck. — Case: Forceps; six coils of funis around the neck. — 
Case : Forceps for danger to child. — Knots in the cord. — Pressure [on the 
cord. — Case: Feet, funis, and head presentation. — Case: Head and funis; 
forceps. — Prolapse of the funis. — Case: Prolapse of funis; interesting 
autopsy of child. — Case: Feet and funis presentation. — Forceps or version. 
— Case: Prolapse of funis; forceps. — Case: Prolapse of funis in a breech 
presentation. — Case: Prolapse of funis. — Conclusions. 

Case 175. — Prolajpse of funis. — JDr, Forman, House 

Surgeon. 

Eliza Lamb ; aged 26 ; Irisli ; admitted to Bellevue about 
the middle of February, 1867, in the eighth, month of her 
first pregnancy. Labor commenced April 2d, at 9 A. m. 
At this time there was well-marked right obliquity of the 
uterus. Dr. Forman recognized a vertex presentation, but 
the head was so high that the position could not be distin- 
guished. The patient was properly placed in bed to obviate 
the uterine obliquity. At half-past nine, while Dr. F. was 
away, the membranes ruptured and the cord prolapsed, the 
head not having yet engaged. Five minutes afterward Dr. 
F. arrived and found a loop of the cord in the vagina. He 
immediately placed the patient on her knees, with her breasts 
down on the bed, and endeavored to replace the funis. But 



COMPEESSION OF FUNIS. 403 

by this time tlie head had become engaged, and his efforts 
were fruitless. In fifteen minutes after rupture of the mem- 
branes the cord had ceased to pulsate. The position of the 
head was E. O. A. From this time the case was left to 
nature. The second stage lasted four hours, and was charac- 
terized by severe uterine contractions. The head seemed 
large in proportion to the pelvis, the parietal bones over- 
lapping about a quarter of an inch. The third stage was 
accomplished in about ten minutes. Child still-born, and 
presented a livid appearance. 

Case 176. — Pelvic presentation / arrest of head in pel- 
vis ; compression of cord ; delivery of child hy traction on 
its lower jaw, — Dr. Forman^ House Surgeon. 

Mar J Eeilev ; aged 23 ; Irish ; single ; admitted to Belle- 
vue March, 1867, in the eighth month of her second preg- 
nancy. Labor-pains commenced in the morning of the 12th 
of April, and when examined four hours afterward, the os 
was found about the size of a silver dollar, and one of the 
child's feet could be distinctly felt through the membranes. 
From this time until the rupture of the membranes three 
hours afterward, the os had gradually dilated to almost its 
full extent ; the feet coming down in the vagina. During a 
severe pain the membranes ruptured, and the feet were born. 
The pains then became so frequent and powerful that the 
body was expelled in a few minutes, but the head was arrested 
in the pelvis, and was not dislodged by several very severe 
expulsive efforts. The pulsations of the cord, which had 
been quite strong, now becoming almost imperceptible. Dr. 
Forman introduced his fingers in the child's mouth, and de- 
livered the head by traction. The child was asphyxiated, 
but was resuscitated after fifteen minutes' labor. The third 
stage was accomplished in fifteen minutes. The transverse 
diameter of the child's pelvis occupied the right oblique 
diameter of the mother's. 



404 OBSTETRIC CLINIC. 

Case 177. — Compression of cord the cause of fmtal death 
in a cejpTidlic jpresentation 'y autopsy of child. — Dr. Forman^ 
House Surgeon. 

Bridget Hanlon; Irish; aged 24; single. Third preg- 
nancy. Admitted to Bellevne April 12, 1867. Labor-pains 
commenced abont fom- honrs before admission, and the mem- 
branes rnptured in the carriage a few minutes before her ar- 
riyal. The patient was immediately sent to the lying-in 
ward, and seen by Dr. Elliot, who was making his daily 
visit. He recognized the os nteri to be well dilated ; large 
and well-ossified head in the superior strait; R. O. A. Foetal 
heart distinct a little below and to the right of the umbilicus. 
The second stage lasted about thi-ee hours. Uterine con- 
tractions frequent, extremely violent, and the child was born 
at 5 p. M. As soon as the head was born, it was noticed that 
a loop of cord— pulseless — protruded from the vagina, lying 
across the child's chest. The child was immediately delivered 
by introducing two fingers in the axilla, but it was asphyx- 
iated, and all attempts at resuscitation proved futile. After 
delivery of the child, a large dose of the fluid extract of ergot 
was given to the mother, firm pressure with the hand made 
over the fundus uteri, friction with ice to the abdomen and 
thighs, and a lump of ice in the vagina, were used to cause 
'Contraction of the uterus and expulsion of the placenta, as 
the woman fiooded a little all the time. These means fail- 
ing, an attempt was made, after twenty minutes, to " press " 
off the placenta, but this also failed. A child was also ap- 
phed to the breast, and a further dose (five drachms in all) 
of the fluid extract given ; but three-quai^ters of an hour 
having passed without effect, and the flow continuing mod- 
erately. Dr. Forman introduced his hand into the cavity of 
the uterus and removed the placenta, having to separate a 
portion which was firmly attached to the fundus. Pains soon 
coming on, the hand, with the enthe placenta and a mass of 
clots, was expelled. The uterus contracted firmly, and re- 
mained contracted until several hours afterward, when she 



COMPEESSION OF FUNIS. 405 

was removed to another bed from tlie necessities of the ward, 
and another hemorrhage recurred, which was readily con- 
trolled bj pressure and cold. 

April 15th. — Doing well. 

Autopsy of child. — This displayed ejffusion of a clear serous 
fluid into the abdominal cavity. Cerebral blood-vessels very 
much congested, although the thorax was first opened and 
the viscera removed. J^o cerebral extravasation nor other 
evidences of disease to be found. Skull very well ossified. 

Case 1Y8. — Transverse position of head i cord around 
nech 'j still-lorn child j' autojpsy. — Dr. Mead, House Surgeon. 

Julia Eegenberger ; aged 25 ; German ; primipara. The 
waters broke May 23, 1867, 3.45 p. m. When first examined, 
the head had engaged in right occipito-iliac transverse position. 
Foetal heart could be distinctly heard. Head descended in 
this position. Pains were very strong, but the head did not 
rotate. The cranial bones overlapped considerably. The 
hand was passed into the vagina, and the head was manually 
rotated during intervals of pain. OccijDut now engaged un- 
der symphysis pubis, and face soon swept over the perineum. 
Second stage of labor 6f hours. Cord was around child's 
neck ; this was not pulsating. Delivery was now accom- 
plished as rapidly as possible, but foetal heart was not audi- 
ble after bii'th. 

Post-mortem examination of chiWs hody. — Sub-pleural 
and sub-pericardial ecchymoses were found. Lungs not ex- 
panded. Liver and kidneys congested. A few small ecchy- 
moses on the thymus gland. Brain, normal. 

Mother discharged entirely well. 

The dangers to the child from compression of the 
funis. — Compression of the funis is probably a more frequent 
cause of foetal death than is generally supposed. We are 
familiar with the danger in pelvic presentations, and espe- 
cially in cases of prolapse, but we cannot recognize its influ- 
ences so satisfactorily in many cases where the circulation 



^ 



406 OBSTETRIC CLINIC. 



of the funis is interfered with, while jet the child and the 
cord are entirely within the nterus. 

The circulation may be interfered with by direct pres- 
sure, by knots in the cord, and by too great traction on the 
cord. Of these, the fii'st is infinitely the most frequent. 
Doubtless, this pressure in utero often provokes such reflex 
foetal movements as may relieve the funis, and so dispel the 
risk. In other cases, the shutting off of the current of blood 
from the mother awakens prematurely the respiratory need 
{Ijesoin de Tesj)irer)^ and the child may present at the au- 
topsy the evidences of death from this cause, as in Case l^o. 
100. In rare cases, after rupture of the membranes, it may 
fortunately happen that the premature respiratory efforts 
may be maintained by such a supply of air as may suffice 
for the child's necessity — a result which we aim to secure by 
pressing back the perineum with the hand when the head is 
retained in pelvic presentations, or by the use of such instru- 
ments as were recommended by Benjamin Pugh.^ 

Cord around neck. — The cord is so frequently around the 
neck when living children are born, as to render us indifferent 
to the risks which many undoubtedly run from this accident. 
Dr. Reed has ingeniously suggested that these coils are formed 
at the time of the passage of the head through the pelvis. 
Still this contingency may cause great danger, and cost the 
child its life. The coils may be so tightly superimposed as 
to produce dangerous and irremediable pressure ; they may 
take up so much of the funis as to involve the risk of their 
being drawn steadily tighter as the head descends, as in Case 
178 ; they may interfere with the advance of the head. 
These conditions are very exceptional, but not the less baleful, 
since for that reason as well as for others they are less liable 
to early recognition ; and because in delivery by forceps we 
may hasten and develop that very danger, from tightening of 
the coils, which hangs over the child. 

* Yide a paper by the author oq " Still-Births," published in the " Transac- 
tions of the New York State Medical Society" for 1867. 



COMPEESSIO^ OF FUNIS. 407 

In such cases the foetal heart is the obstetrician's com- 
pass. 

Case 179. — Delivery loith forceps for the sake of the 
child ; necTc encircled six times hy funis. 

IsLj friend Dr. Eustace Trenor sent for me on the 31st 

of Jannary, 185S, to see Mrs. IT , a primipara, aged 27, 

at full term, well built, robust, with a well-formed pelvis. 
Seen by Dr. T. at 8 p. m., 30th. Membranes then ruptured 
three hours. Pains irregular and feeble. Condition good. 
Os just admitted a finger. Summum of foetal heart intensity 
to the left. 1^0 uterine souffle. 6 a. m., Zlst. — Os fully di- 
lated. Pains strong since 3 a. m., and so continued until de- 
livery. 9.30 A. M. — Dr. Trenor sent for me, on account of 
non-advance of the head, anxious expression of patient's 
countenance, and dry tongue, and because he could not sat- 
isfy himself that the foetal heart continued audible. I saw 
her at 11 a. m. Head pressing against bony outlet. Post. 
font, to right acetab. Yagina cool ; perineum rigid. Foetal 
heart extremely indistinct, but yet, as I thought, audible. 
Decided to deliver, principally for the child's sake. Applied 
forceps with concavity directed to right acetabulum. Did 
not need pivot. Delivered promptly a living child, weighing 
six and a half poimds, with cord six thnes around neclc. Pa- 
tient under the influence of chloroform given by Dr. T. 
Placenta came away nicely. On cutting the cord close to 
the placenta, we wrapped it six times around the child's 
neck, when the small amount left satisfied us that it was the 
probable cause of delay. 

Perhaps in the following and similar cases pressm^e on 
the cord was the source of danger : 



'&^ 



Case 180. — Forceps for danger to child, 

Novemler^ 1857.— Mrs. , aged 23; first; L. O. A. 

Pains good, parts well relaxed, os dilated, head in inferior 
strait, patient imder chloroform. In short, every thing prom- 



408 OBSTETEIC CLINIC. 

ised a natural and easj labor. On auscultating the foetal 
heart — as it is always my habit to do from time to time — I 
was sm'prised to find it growing slow and feeble. As it did 
not rally, I requested Dr. G. A. Peters (who was in the 
vicinity) to manage the chloroform, and I delivered a living 
female child, quite livid, and partially asphyxiated, with for- 
ceps. Eevived by the customary means. Mother did well. 

Knots on the cord. — Several of these cases have come 
under my observation, but I do not remember that they were 
a cause of death in any other case than that of a prematm^e 
foetus about three months old. In this case, the cord was 
drawn in a tight knot between the foetus and the placenta, 
and was, in the opinion of Dr. Gouley and others, as well as 
of myself, the cause of death. 

PressiLTe on the cord. — ^My last service in Bellevue, on 
which this work is based, presented many examples of danger 
from pressure on the cord. In the case of Julia Eegenberger, 
ISTo. 178, such was undoubtedly the cause of death, and the 
sub-pleural and sub-pericardial ecchymoses a pathological in- 
dication of the efforts made by the foetus for premature res- 
piration. 

In the case of Bridget Hanlon (No. 1Y7), I do not doubt 
that pressure on the funis was the cause of the child's death, 
though there were no evidences of premature respiration. 
The effusion of clear serum into the abdominal cavity with- 
out evidences of inflammatory action is of interest in rela- 
tion to similar appearances in cases adduced of death from 
prolapse of the funis. Such contingencies as occurred in this 
case are apt to be unrecognizable. 

Case No. 176, of Mary Eeiley, offers an additional illustra- 
tion of the dangers from tliis risk in pelvic presentations, and 
of the advantages of timely and intelligent care. TVTiile, how- 
ever, many of these dangers may be irremediable and un- 
avoidable, one occurred in case No. 175, which pecuHarly 
appeals for prompt and skilful aid, though in any event there 
must ensue a 2:reat loss of foetal life. 



PEOLAPSE OF FimiS. ^ 409 

Pi'olajpse of the funis is recognizable, and demands im- 
mediate treatment. If the funis cannot be replaced while 
beating satisfactorily the child mnst be immediately deliv- 
ered by forceps or version, as in the following case : 

Case 181. — Head and funis ; forcejps. 

Mary Loftus ; aged 29 ; third labor. Head presentation 
complicated by prolapsed funis. She had been in labor ^yq 
hours, when I delivered her with forceps of a living male 
child, partially asphyxiated. Chloroform. January 20, 1854. 
Out-patient, Lying-in Asylum. 

Case 182. — Feet^ funis, and head ^presentation ; version; 
child dead hefore the operation. 

Mary Powers. December 11, 1853. Lying-in Asylum. 
Out-patient. Report condensed from the notes of Dr. "Wm. 
H. L. Starks, under whose care she was placed. 

December 10th. — At midnight labor commenced. Second 
confinement. Membranes descending into the vagina like 
the "finger of a glove." Os somewhat rigid. Funis and 
feet found to present. Funis pulsating feebly. TJ a. m. — 
Membranes ruptured. Liquor amnii less than usual. Pains 
scarcely returned until 4 p. m., when they gradually resumed 
their frequency and force. The fanis had defied all attempts 
at reposition. I was then sent for by Dr. Starks, and arrived 
at about 7 o'clock, and found the feet, funis, and head pre- 
senting; first position. Funis pulseless. The patient having 
been brought under chloroform, I delivered by the feet, bring- 
ing the face into the hollow of the sacrum. Child still-born. 
Cold, pressure, and 3 vj of the saturated tincture of ergot 
contracted the uterus. Hemorrhage slight. Perineum some- 
what lacerated. By the 22d she was able to go about the 
room, thanks to the very thorough care and prompt attention 
to every symptom of a threatening character rendered by 
Dr. Starks. 



410 OBSTETRIC CLmiC. 

"We cannot, however, be certain tliat tlie child will be 
born alive, though we succeed in promptly replacing and 
retaining the funis beyond the ordinary risks of pressui-e, as 
is well shown in the following history, in which perhaps the 
cause of death was from pressui'e on the cord by the breast, 
as in the case of Bridget Hanlon, Ko. ITT : 

Case 183. — Prolapse of funis ; interesting autopsy of 
child ; intra-uterine ascites and hydrotJiorax ; apojilexy. 

Mary Matthews ; aged 2T ; married ; fell in labor for the 
fourth time on the 10th of JN'ovember, 1861, at 2 p. m., in 
Bellevue Hospital. Previous labors natural. At 6 p. m. the 
membranes ruptm-ed, and the cord prolapsed. The House 
Physician, Dr. Yedder, could not readily succeed in repla- 
cing the cord, and sent for me. I found the patient placed in 
the position recommended by Prof. T. G. Thomas, of this 
city, with a large loop of pulsating fcmis in the upper part 
of the vagina. The os uteri was fully dilatable, the arc of 
the parietal bones just dipping within the brim of the pelvis, 
and the foetal head quite movable. Pelvis well formed. My 
fct care was to determine from which side the funis prolapsed, 
a point, in my opinion, of practical importance ; since by 
endeavoring to return the loop on the opposite side it might 
thus be tightly drawn over the presenting part of the child, 
and danger follow, even though on that side there might be 
a greater amount of space between the presenting part and 
the pelvic brim. • Finding that the cord had prolapsed on 
the left side of the pelvis, I proceeded with great gentleness 
to press it down the inclined plane, and succeeded in doing 
so to the level of the pelvic brim, when, as in other of 
my published cases, it was again driven up-hill into the 
vagina by a strong uterine contraction. Leaving the woman 
in the same position, I prepared myself to dehver promptly 
with the forceps if the manipulation should fail, and this 
notwithstanding the position of the foetal head. Reintrodu- 



PEOLAPSE OF FUNIS. 411 

cing, as before, my entire liancl witliiii tlie ra^o-iria, I again 
gently recommenced tlie manoenvre, and tliis time pushing 
the head to the right side of the pelvis, carried my hand be- 
yond the eraninm, and only left the cord when on a level 
with the foetal chin. Before dropping it, as is always my 
custom, I satisfied myself by pressure between the fore and 
middle finger that the pulsations were good and strong. It 
did not again prolapse. On the 11th, at 4 a. m., the foetal 
heart pulsations were distinctly heard by Dr. Yedder — eight 
hom's after the replacement. At 2 p. m. of the same day she 
was dehvered by very powerful uterine contractions of a still- 
born male child, weighing nine and a half pou.nds, and 
well formed. Dr. Yedder states that there was a long 
interval between the birth of the head and that of the shoul- 
ders, as there often is in these labors where very powerful 
uterine contractions have been necessary to force the head 
through the straits, and as the shoulders came into the world 
Dr. Yedder remarked that the funis was doubled and placed 
in front of the breast. Length of cord normal. Placenta 
normal. Microscopic examination by Prof. A. Flint, Jr. 
Dr. Yedder inflated the lungs, but to no purpose. I saw the 
child two hours afterward, when its head was markedly livid, 
and on flexion fluid blood ran from the nose. On the follow- 
ing day an autopsy was made in presence of the class, by 
Dr. Teats, Assistant Curator of the Museum, and in order to 
diminish, as far as possible, all appearances of cerebral con- 
gestion, I requested him to open the other cavities first. 
When the peritoneum was opened, it appeared to be about 
half full of a sero-sanguinolent fluid, containing no lymph or 
pus. There was no false membrane anywhere within the 
abdomen, the organs of which appeared healthy, with the 
exception that the liver was somewhat darker than usual. 
Both pleurae and the pericardium were from one-third to one- 
half full of a similar fluid, without token of other inflamma- 
tory action. The lungs crepitated, and the thoracic viscera 
were well formed and healthy. Dr. Yedder had inflated the 



412 OBSTETRIC CLmiC. 

Inugs. Tlie child liad never gasped. On removing the calva- 
rium and dura mater, the scalp was found to present the 
customary congestion and jellj-like appearances in the caput 
succedaneum. "No effusion between the cranium and dura 
mater. Yessels of convex sm^face of hemispheres remarkably 
congested, and a thin sheet of currant-jellj-like blood poste- 
riorly over the convex surface of each hemisphere. The 
same extravasation had occurred at the base over the lower 
part of each posterior lobe ; but there were no other clots, 
though the puncta vasculosa, choroid plexus, and all the cere- 
bral tissues witnessed to the violence of the congestion. 

JRemciTlis. — This case affords a happy illustration of the 

success which will attend the patient use of the manoeuvre 

- proposed by Prof. T. G-. Thomas, and although unsuccessful 

is not the less adapted to prove its advantages in a very 

difficult class of cases. 

In considering whether, in such difficult cases, a porte- 
cordon might not prove of assistance in the necessarily deep 
depression of the cord, I incline to the belief that the advan- 
tages might be more than counterbalanced by the deprivation 
of the power to determine at the last moment whether or not 
the pulsations continued. If, however, a case should chance 
to occur in which the cord had to be carried thus deeply 
^vithin the uterus, and the presentation interfered with proper 
manipulation, the porte-cordon might prove useful. 

The cause of the effusion into the thorax and peritoneal 
cavity, and the period of its occmTcnce, are problems not 
easy of solution. It is not likely that the cord suffered any 
great compression dm-ing the time of its prolapse, nor during 
that requii'ed for its reposition, wliile such pressure as it might 
have been subjected to would of course have been materially 
expended on its vein, and have thus deprived the child of 
blood, and diminished the tendency to other congestion 
than such as would follow deficient oxygenation. The 
apoplectic effusion probably occurred during the passage of 
the head through the outlet, when Dr. Yedder remarked that 



PEOLAPSE OF FUNIS. 413 

the expulsive pains were as strong as lie should ever expect 
to see them, and all their force needed ; or it might have 
occurred after the birth of the head, during the interval 
which elapsed before the birth of the shoulders, or from both 
of these causes combined. 

If the effusion be admitted to have occurred during intra- 
uterine life from causes not entirely appreciated, then cer- 
tainly the case afibrds a happy illustration of the value of 
post-mortem examinations of still-born children, as otherwise 
such a condition must have passed without suspicion — if, in- 
deed, the death were not simply assigned to prolapse of the 
funis. The mother died from puerperal fever, which then 
existed in the hospital. 

The rapidity with which death often follows prolapse of 
the funis is well shown in the following history : 

Case 184. — Feet and funis presentation ', stiU-horn child. 

]\Iary ; single ; aged 2T ; in labor in Bellevue from 

February 10, 1862, at 3 p. m., to February 11, at 3 a. m., 
under the care of Dr. Lowell, House Surgeon. Female 
child, weighing seven pounds, presented both feet, and when 
they were in the vagina, a large coil of funis prolapsed be- 
low the vulva. Dr. Lowell went instantly, but found no 
pulsation. Delivery easy. l!To respiratory effort made. I 
directed the autopsy fifteen hours after death, before the 
class. Weather cold. Peritoneal, pleural, and pericardial 
surfaces healthy. Lungs in foetal condition, free from dis- 
ease. On carefully removing the skull-cap, without cutting 
the brain, | j of dark, bloody. serum escaped. Brain fii-m, 
and came out intact. Serous effusion to an abnormal ex- 
tent in both ventricles, especially the left. 

Forceps or version, — If the funis should prolapse at a pe- 
riod of the labor when very prompt delivery by forceps is 
possible, they had better be applied at once. Such decisive 
treatment will probably afford the child a better chance for 



414 OBSTETEIC CLINIC. 

life than any other. If the alternative be delivery by ver- 
sion, the prospect of an easy operation must be seriously 
considered ; for if the funis be subjected for any time to the 
risks fi'om pressure by the operator's arm, or by the contin- 
gencies of pelvic presentations, the chances of the child are 
most materially diminished, while the dangers to the mother 
are increased. 

It is evident, therefore, that in delivery of the child by 
forceps or version in these elective cases two questions arise : 
first, the absolute facility with which either may be per- 
formed; second, the relative fitness of the practitioner in 
charge for the performance of either or both operations. It 
is thus evident tliat one man is warranted in operating in 
cases in which another had better abstain ; and while thus 
the necessity for other methods of treatment than operative 
is diminished for the expert, it is obvious that very many 
cases must always occm- in which operations are undesira- 
ble or impossible, and in which the practitioner only aims at 
reposition of the cord in utero, and its retention there. 

Sometimes a man may so desire to avoid an elective 
operation that he may waste time unnecessarily, to the pre- 
judice of his 23atient, as I did in the following case : 

Case 185. — Prolapse of funis ; Prof Tliomas^ s j^lan ; 
forceps. 

Joanna Burke; aged 24; primipara; Bellevue. Drs. 
H. r. Andrews and E. B. Mamy. May ^th^ 1858, 10 p. m. 
— Os size of a dime, membranes to be felt during a pain. 
4.45 A. M. — Membranes had ruptured ; water gone ; several 
loops of funis without the os uteri, and pulsating strongly. 
Dr. Andrews faithfully tried to reposit the cord by Prof 
Thomas's plan, but without success; patient unruly. The 
woman was kept in Prof. Thomas's position for more than an 
hour; I was then sent for, and the patient placed on her 
back, and chloroformed to diminish the uterine contractions. 
Went instantly, and arrived a few minutes before .six. Di- 



PEOLAPSE OF FUNIS. 415 

rected Dr. Lambert to spring on tlie bed and hold the 
woman's hips in the exact position recommended, detailing 
another gentleman to watch the respii'ation, as she was fully 
under the influence of chloroform ; and, by introducing my 
whole hand in the vagina, succeeded in repositing the 
scarcely pulsating funis within the uterus, to such an extent 
that the two fore-fingers, buried within the uterus, could 
barely touch it. But, when the next pain came on, it drove 
the funis up the reversed superior strait, so as to fill the va- 
gina to the vulva. There was no time to lose, and having 
the woman rapidly placed on her back, I delivered her with 
all haste possible. The head had barely completed the 
movements of descent, and was yet in the superior strait, 
and my forceps were thrown over one oblique diameter, and 
the child delivered almost as rapidly as I can write this de- 
scription. The pivot was not regarded much, and the child 
was marked over the lip with one blade, a result which could 
have readily been avoided if I had adjusted it accurately be- 
fore making my tractions. But I had waited so long in the 
hope of success, in the manoeuvre described, that I did not 
dare delay one instant. The child was asphyxiated, but 
was restored to life. It died on the fourth day, from inan- 
ition, with which I think that the sore lip had something to 
do. Mother did well. 

In repositing the cord in utero it is obvious that there are 
difficulties which cannot be removed, but which may be ma- 
terially diminished. These arise from the slippery character 
of the uterine walls and vagina of the mother, and of the 
funis itself. These conditions, with the length and small 
diameter of the cord, the influence of the uterine contrac- 
tions, and the attraction of gravitation, combine to render 
the operation one of difficulty. 

It is not sufficient that the cord be fully and entirely re- 
posited within the uterus, for, as shown in some of my cases, 
the uterine contractions may force the funis out of the vulva. 



4:16 OBSTETEIC CLmiC. 

even when tlie patient is so placed that the attraction of 
gravitation must be overcome and the cord pushed up-hill. 
This is further illustrated in the following case : 

Case 186. — Prolapse of funis in a hreech presentation. 
— Nursery and Child's Hospital — Dr. Barrett, House Phy- 
sician, Reporter. 

Lizzie H ; a native of Scotland; aged 23 ; second preg- 
nancy ; aborted in the first at three months. Last menstru- 
ation January 24:th. Labor-pains commenced 10 p. m., Oc- 
tober 29, 1866. 4 A. M. — "Waters broke while straining at 
stooL She then walked fi'om the basement floor where she 
had slept, to the third story, where the lying-in ward is situ- 
ated. Upon examination, a few minutes after admission, a 
loop of the cord was found protruding from the vulva, and 
pulsating at the rate of 120 a minute. Os fully dilated, and 
the breech presenting (right sacro posterior) in the superior 
strait. Patient immediately placed in the position recom- 
mended by Prof. Thomas, and the cord easily reduced several 
times ; but it was found impossible to retain it in place, each 
successive pain forcing it back again. 

The pains were neither very frequent nor strong, and the 
pulsations of the cord were rapidly becoming diminished in 
number and strength. 

The attending physician, Dr. Foster Swift, was then sent 
for, and he and Dr. Hull arrived at 1 o'clock. They found 
the cord still pulsating, but only at the rate of 40 per minute, 
and confirmed the facts previously ascertained as to presenta- 
tion and position. 

Dr. Swift then proceeded to deliver the child, by pulling 
down the feet and assisting the delivery of the head, which 
he accomplished in a short time, but too late to save its life. 
Measures resorted to for resuscitation were, dipping the child 
into warm and cold water, spanking it, Marshall Hall's 
method, and artificial inflation of the lungs, using for this 



PEOLAPSE OF FUNIS. 417 

purpose tlie svi'inge connected witli Barnes's dilating appa- 
ratus ; but all efforts proved ineffectual. 

The pelvis was large. The attachment of the placenta 
was not ascertained. There appeared to be an unusually 
large amount of liquor amnii, for, notwithstanding the forci- 
ble and sudden rupture of the membranes, and the subse- 
quent walk up-stairs, it still continued to gush forth in con- 
siderable quantity at every contraction. The cord also was 
long, measming thirty-six inches in length. There was no 
appreciable obliquity of the uterus. 

November Ist. — (Third day after conffnement.) The wo- 
man is doing well. 

Autopsy of child witnessed by Dr. Elliot, and the parts 
displayed at his clinic in the Bellevue Hospital. 

Case 187. — Prolajose of funis. 

Dr. "Warner sent for me on the 10th of November, 1864, to 
a woman in her second confinement, whom the doctor had 
first seen when in labor, with the funis prolapsed, and the 
head presenting. He placed the woman in Thomas's position, 
and gathering up the coil, replaced the funis in utero twice, 
passing it over the face of the child. On each occasion the 
next pain drove it up-hill and out of the uterus and vagina. 
When I arrived the patient was still in Thomas's position, 
and the cord external to the vulva, cold and pulseless. There 
being no evidence of the existence of twins, we decided not 
to make any further efforts. 

Conclusions. — It follows, therefore, that the cord must be 
carried completely and well within the uterus; the hand 
being introduced in the vagina if necessary, and the porte- 
cordon possibly of advantage ; and that the operator must 
watch over his case to observe whether the funis be retained, 
and the foetal heart continue to beat. It has been recom- 
mended by authors, who understood these facts, that the cord 
should be carried so far within the uterus as to hang it over 
27 



418 OBSTETEIO CLINIC. 

the knee or arm of tlie foetus, or to coil it behind the head, 
before the hand were withdrawn. It is certain that reposi- 
tion alone is unsatisfactory unless the cord be retained ; and 
the retention must be due to the fact that it should fortu- 
nately slip or be carried into a place where it is less exposed to 
the uterine contractions, or so sheltered behind a presenting 
part that it cannot again be driven out. 

Since we cannot change the size, shape, or slippery char- 
acter of the cord and maternal passages, we cannot facilitate 
this procedure more certainly than by changing the dii-ection 
of the long axis of the uterus so that the attraction of gravi- 
tation will operate toward the uterus instead of toward the 
sacrum ; to reverse, in short, the direction of the superior 
strait, by placing the patient on her knees and breasts. 

This position has been prominently brought forward by 
Prof. T. G. Thomas of this city, in a paper read before the 
'New York Academy of Medicine, and widely pubhshed. 
His claims to priority have not been challenged in the Amer- 
ican or English medical journals, although it appears that 
jSc/imidfs Jalvrhiich^ 1856, Band 91, S. 200, contains the out- 
line of an article on the subject by Dr. Kiestra, published 
previously to Dr. T.'s, in which the method is recognized as 
Daventer's, and revived. 

These facts illustrate the well-known difficulty of estab- 
lishing the priority of an original observation, since in all 
departments of science the same ideas occur to independent 
and equally original observers. Before Dr. Thomas read his 
paper on " Postm-al Treatment of Prolapse of the Funis," he 
consulted me as to whether the old authors contained any 
thing on the subject, and he and I have been equally igno- 
rant that the observation had been previously made, until 
the facts were recently called to our attention. 

It is to Prof. Thomas that American and English ob- 
stetric literatm-e owes the method, and it is just and proper 
that it should rightfully be known in that literature by his 
name. 



PROLAPSE OF FUNIS. 419 

In appreciating tlie value of the method, the cases which 
are published in this volume suffice to show that it may be 
readilv successful and demand but trifling effort ; but they 
show that imless the cord be sheltered behind some part 
of the foetus capable of retaining it in utero, the funis may 
be again and again driven up-Jdll by the nterine contrac- 
tions ; they show that if the cord be retained, and the foetal 
heart continue to beat for honrs, the child may be unfitted 
for extra-uterine Life by effusions which probably depend on 
interference with the circulation during the prolapse or 
reposition ; they show that if prompt operative delivery be 
possible, it had better be resorted to without delay rather 
than to risk the danger attending difficult or prolonged ma- 
nipulation. 

It is the best method which can be devised to assist our 
manipulations in the reposition of the funis ; it will save the 
lives of children which would otherwise be lost, and should 
be familiar to all who practise midwifery, but it is only one 
of the means for this end, and cannot relieve the practitioner 
from the necessity for continued alertness and readiness with 
other measures, nor as greatly diminish the danger and diffi- 
culty of the complication as is to be hoped and desired. 



■■ 



CHAPTEE XYI. 

EETEO-PHAETNGEAL ABSCESS. 

Case: Eetro-pharyngeal abscess in an infant. — Case: Eetro-pharyngeal abscess 
in a boy of seven months. — Remarks. — Case: Cellulitis (erysipelatous) in a 
new-born child. — Value of diet and hygiene in infancy. — Report on the 
pulse, weight, and respiration in infancy, with the influence of different 
kinds of alimentation on the state of health, by Dr. E. D. Hudson, Jr. 

Case 188. — Eetro-pharyngeal alscess in an infant. — Dr, 
Mead, House Surgeon. 

Patrick Lynch, aged four months, born in Bellevne, liad 
remained in the hospital with his mother, as the latter had 
suffered from a broken breast, which had, however, healed 
perfectly. On the 7th of May, 1867, my attention was called 
to him by Dr. Mead, and I recognized the following symp- 
toms : He was asleep at the time, and appeared well nour- 
ished, but quite pale. His breathing was rapid but not other- 
wise difficult during sleep. The head was forcibly thrown 
back, and retained in that position when he awoke, and the 
muscles of the posterior part of the neck were very rigid. 
On the right side of the neck, behind the angle of the jaw, 
there was marked tumefaction, with the feeling of deep 
fluctuation. A superficial abscess had been opened in this 
region on the 15th of April, and had completely healed. 
During the month of May the mother had noticed first, that 
the child did not breathe easily, and subsequently that its 
deglutition became unsatisfactory, and finally so difficult 
that the milk drawn from the breast would regurgitate from 



EETEO-PlHAEYNGEAL ABSCESS. 421 

the moiitli. The child was evidently hiiiigry and did its 
best to obtain milk, Trhich it was unable to swallow. On 
depressing the tongue and carefully examining the throat, 
nothing abnormal whatever could be seen except some red- 
ness. The finger, however, could detect a bulging fluctu- 
ating tumor on the posterior wall of the pharynx. Having 
diagnosticated a retro-pharyngeal abscess, I guarded a bistouri 
with plaster, and made an incision in the median line, 
when a gush of about an ounce of greenish fluid followed 
the finger as it was withdi-awn. This relieved the little fel- 
low's breathing, and within two hours he could nurse and 
swallow without difficulty; and the mother having only milk 
in one breast, other women in the ward aided in satisfying 
the child's hunger. The deep fluctaation on the side of the 
neck and the muscular rigidity disappeared, and all went 
well until May 11th, when some trouble in deglutition 
recurred. By the 12th the head was again thrown back in 
its old position, and by the 13th the patient swallowed as 
badly as before. On examining the throat with my finger I 
recognized the site of the old incision, and a fluctuating 
tumor in the same situation. 

I then brought the child before the class, when some of 
the gentlemen recognized the fluctuation, and I made a 
second incision, the pus and blood escaping on this occasion 
through the pharynx as well as from the mouth. At this 
time the full escape of pus from the mouth did not 
happen at once, some more being expectorated after a few 
minutes. The same prompt relief to all the symptoms fol- 
lowed, and the child was discharged perfectly well. 

Case 189. — Betro-;pJiaTyngeal abscess in a lx)y of seven 
months. 

This healthy, well-developed boy, aged seven months, the 
child of healthy parents, and nursed by its mother, had been 
under the care of Dr. Finlay for parotitis, from which other 



422 OBSTETRIC CLINIC. 

members of the family were suffering. He was first taken 
on tile 28th of January, 1867, and on the 3d of February 
there T^^ere dyspnoea and bronchial catarrh, with difficulty 
of breathing and in nursing. At Dr. Finlay's request I saw 
him in consultation on the Yth. He was drowsy, but fretful 
and uneasy, remained sitting on the lap, and objected to be 
laid down. His face was dark in color, the eyes suffused 
and dull. He seemed to breathe with some difficulty, ir- 
regularly and in a noisy manner. He swallowed with the 
greatest effort, and the greater portion if not all of the milk 
taken from the breast regm-gitated at once from his mouth. 
The site of the parotitis was yet swollen. ISTothing was seen 
on examining the throat. The touch, however, recognized a 
soft tumor below the level of the epiglottis, and behind the 
pharynx. At an early hour on the following morning, the 
family consenting, and the same conditions still recognizable. 
Dr. Finlay carried down a guarded bistouri on his finger, 
and opened the abscess. A gush of jpus flooded the mouth, 
and escaped as the instrument was withdrawn. All the 
symptoms ceased at once, the child slept well and naturally, 
nursed well, and needed no further attention. 

Remarks. — The infrequency of retro-pharyngeal abscess 
is such that men in very extensive practice rarely meet with 
it, and it is probable that children die from this disease 
without the diagnosis having been made. Indeed, I have 
recently been informed of a case in which the cause of death 
was only appreciated at the autopsy. Dr. West has only 
seen two cases in his. extensive field of observation. 

Abscesses in the sides of the neck, behind the angles of 
the jaws, may break into the pharynx as well as discharge 
themselves, or be opened externally, without giving rise to 
the symptoms met with in my two cases. I have seen such 
instances where the probe could be subsequently passed 
from without and be seen in the mouth. The abscesses may 
be retro and latero-pharyngeal. In searching for the causa- 



RETEO-PHAEYNGEAL ABSCESS. 423 

tion of tliese abscesses we must take cognizance of the con- 
stitution of tlie patient and of the state of health just before 
the development of the symptoms. A scrofulous constitu- 
tion, with glandular swellings of the neck, may give rise to 
abscess, and, on the other hand, the early stages of extensive 
retro and latero-pharyngeal abscesses may be overlooked, in 
the belief that there is only some glandular swelling of the 
neck. The exanthemata, and especially scarlatina and paro- 
titis, as in Case 189, are capable of giving rise to such condi- 
tions of the tonsils and pharynx as predispose the patient to 
this disease. Caries of the bodies of the vertebrae may cause 
abscess here as in the neighborhood of other diseased bones, 
but it may well be expected in these cases that the more 
gradual invasion of the symptoms, and their more pronounced 
character, may lead to the assignment of the abscess to its 
special origin before it shall have attained such dimensions 
as may threaten life. 

In idiopathic cases it is not always possible to appreciate 
the exciting causes. The bland nourishment, of equal tem- 
perature, obtained from the breast, excludes the probability 
of suspecting irritation from any aliment or foreign body in 
the throat. Still, it is wise to examine carefully into the 
diet, and learn the character of those who have had charge 
of the child. 

I was once called to one of my little patients, who cried 
whenever he attempted to swallow, and had done so since 
his breakfast, although he had not suffered previously. He 
had taken nothing for his breakfast but bread-and-milk. On 
examining the throat, I saw nothing abnormal, and supposed 
that the trouble must be very trifling. Still, as he com- 
plained greatly, I made a more thorough examination, when 
I recognized far down in the pharynx a splinter of wood fast 
in the mucous membrane, which I withdrew with forceps, 
and the trouble ceased. How a splinter of wood was swal- 
lowed with his bread-and-milk was not apparent, and could 
not have been foretold. 



424: OBSTETRIC CLINIC. 

Some hysterical nurses, or those with eyil intent, may 
cause their little charges to swallow pins and other articles 
capable of producing harm. These may be seen in some 
cases coming from the anus, and stained by their passage 
through the intestines. 

It follows, therefore, that, in the examination of the 
throats of little children, where the unaided eyesight fails to 
appreciate the cause of irritation, the finger and the laryn- 
goscope should be used to complete the diagnosis. 

When a retro-pharyngeal abscess is recognized, it should 
be opened promptly, for the relief is as immediate as it is de- 
sirable. There is but a trifling risk in the incision, and but 
a slight risk of mistake in the diagnosis. I have read the 
details of a case where a new-born child was unable to swal- 
low on account of the pressure on the oesophagus from a cyst 
which had developed during intra-uterine life. Could that 
have been recognized, it would evidently have been better if 
an incision had been made. 

We have no right to anticipate the risk of wounding any 
vessel in the site of the incision in the median line, and we 
cannot be responsible for such anomalies as existed in a 
case reported by Eeatty in his '' Contributions to Medicine 
and Midwifery," page 522, in which a '' fish-bone stuck in the 
throat of a patient, who applied to an experienced sm-geon for 
relief This gentleman attempted to push the bone down the 
throat with a probang, when suddenly there came a great 
gush of blood, and the patient fell dead. It was found that 
the arteria inominata had dipped down between the trachea 
and the oesophagus, just at the spot where the fish-bone had 
lodged, the point of which had been forced by the probang 
into the artery, and thus caused the death." 

In the- two cases of retro-pharyngeal abscess which I have 
described, the character of the breathing varied. In the hos- 
pital case, the head was thrown back in an exaggerated man- 
ner, as it might be in cases of true croup, hut the child did 
not seem desirous of being raised to the erect posture. In 



RETEO-PHAHYITGEAL ABSCESS. 425 

the otlier one, this was imperatively sought, and such snatches 
of sleep as were taken were taken in the sitting position. In 
this latter case, the commencing duskiness of the face, the suf- 
fusion of the eyes, the labored and loud inspiration, with the 
intervals of stupor, rather than sleep, would lead the physician 
to look fii'st for some obstruction in the mndpipe, from false 
membrane, bronchitis, spasm, or thickening of the 'glottis or 
aryteno-epiglottidean folds. And next the suspicion of lesion 
of the nervous centres would be awakened. In some of these 
cases this latter suspicion might be strengthened by facial 
paralysis, which has sometimes occurred. If unrelieved, the 
circulation of the brain may be so disturbed and the return 
of blood therefrom so impeded by the swelling, as to lead to 
death from cerebral congestion, and to develop convulsions. 

The differential diagnosis is to be based on the absence of 
thoracic auscultatory signs of disease, on the absence of false 
membrane in the throat, on the gradual development of 
symptoms in which difficulty of deglutition with the desire 
for food take prominent rank, in the occurrence of inflam- 
matory swelling by the angle of the jaw, but above all is it 
to be based on thorough examination of the pharynx with 
the finger. 

This examination is paramountly necessary in those cases 
of vertebral or exanthematous disease, where difficult deglu- 
tition with stiffness in the movement of the head and neck 
attract attention. If the abscess commence in the submu- 
cous tissues of the pharynx, it may not be possible to arrest its 
march. Cold or hot gargles and poultices, possibly leeches in 
the adult or the robust and well-grown child who has passed 
the period of infancy, scarifications of the pharynx and coun- 
ter-uTitation, with warm or iced appHcations to the sides of 
the throat, are the remedies which suggest themselves for 
trial. If the trouble originates in the mucous membrane, 
there may be a greater hope for timely treatment, and in the 
application of the scarificator, of astringents, the nitrate of 
silver, and the chlorates of potash and soda. 



426 OBSTETEIO CLmiC. 

Ill neitlier of these cases recorded, were injections of the 
abscess subsequently used. These, however, are recommend- 
ed on high authority.* 

Somebody has said that we have made great advances in 
medicine, but that we cannot tell why a pimple should come 
in a particular part of the body, a truth of a humiliating 
character. Nor can we always say why large abscesses should 
occur now here, now there, in the body, but our most im- 
portant duty is to recognize them early and treat them ap- 
propriately. 

In the following interesting case, occurring during my 
service in April, 1867, it may be questioned how far the fall 
from the bed influenced the subsequent phenomena ; though 
I have no doubt, myself, that the affection was of an erysip- 
elatous character, even though connected with the injury. 

The atmosphere of a general hospital must, of necessity, 
increase the liability to such diseases, and I have more than 
once witnessed the development of erysipelatous affections of 
the neonatus, occurring both when puerperal fever was rife, 
and when — as in the month of April — there existed no 
marked tendency to the disease. 

Case 190. — Cellulitis {erysipelatous) in a new-horn child , 
incisions / recovery. 

Mary "Wall ; aged 26 ; United States ; married ; second 
pregnancy. Labor commenced in Bellevue, March 25th, at 
11.30 A. M. L. O. A. First stage, eighteen and one-half 
hours ; second, half an hour ; third, ^lnq minutes. Labor 
natural in every respect. Male child ; weight, eight and a 
half pounds. Two days after delivery the child fell out of 
the mother's bed, but she did not call attention to the baby 
until the following day, when no evidences of any injury 

* Vide an excellent article by Dr. Charles M. Allin, with a statistical table of 
fifty-eight cases, m i\\Q Neio York Journal of Medicine^ November, 1851. 



EETEO-PHAETNGEAL ABSCESS. 427 

coiild be detected. But on tlie third day after tlie accident 
Dr. Xicoll recoo-nized o-reat redness and tenseness of the tis- 
sues over the cla^dcle and shoulder, extending abont two 
inches in every direction. The child suffered very little con- 
stitutionally, but manifested a great deal of pain when the parts 
were touched. 'No fracture or dislocation, or injury to joint. 
Bowels regular. Nui'sed well. On the following day the ery- 
sipelatous redness had extended over the thorax in front and 
behind, and was extending upward over the occipital bone. 
The tissues were of a dusky hue, very tense, and oedematous. 
!Xo fluctuation. More constitutional disturbance. Does not 
nurse as well. Lead and opium wash has been used ; changed 
to day by Dr. Elliot to an ointment with the same ingredi- 
ents. Mother and child transferred to a medical ward. Dr. 
Henry F. Walker, House Physician. April 4^A.-^Shown to 
the class. Fluctuation evident. Free incision anteriorly at 
middle of clavicle ; posteriorly at middle of spine of scapula. 
Laudable pus flowed freely. Dressed with poultices sprinkled 
with lead lotion. Little constitutional disturbance. N^urses 
well. Xo disturbance of digestion. April 1th. — Erythema- 
tous redness of buttocks, which yielded promptly to lead- 
water. Erysipelatous redness of shoulder removed. Dis- 
charge less abundant. Lint and cerate. Vlth. — Almost 
entirely healed. Transferred to convalescent ward. April 
^^th. — Another outbreak of erysipelatous recfeess in original 
site, followed by a little pus. After this there were several 
slight incisions necessary for relief of pus, and the parts were 
left hard and drawn from the adhesion of the cellular tissue. 
The mother watched the child devotedly, and they left the 
hospital in June, a small discharge of pus continuing. 

Yaliie of diet and hygiene in infancy. — In this case the 
success of the treatment in spite of the relapses was para- 
mountly due to the devotion with which the mother watched 
the child, and her ability to furnish it with an ample supply 
of good breast-milk. 



^ 



428 OBSTETEIO CLINIC. 



I am no friend to the bottle for babies, regarding nothing 
as better proven than that the probabilities of healtliy devel- 
opment in infancy are in direct ratio to the amonnt, quality, 
and duration of tlie supply of breast-milk. 

For any baby called upon to endm-e the prostration and 
sufferings inseparable from the formation and discharge of a 
large abscess, the questions of diet and hygiene are para- 
mountly important. Such a one, if brought up on the bottle, 
had better, as a rule, be promptly put to the breast, and if 
possible such changes made as its sanitary surroundings may 
demand. 'We have no time to lose with babies. Their 
necessity for nutrition is too active and imperative to admit 
of delay. If the balance be lost for a while, there is too 
great danger that it may not be regained, and the little one 
recover from its ailment only to fall a victim to infantile 
atrophy, and those diseases which develop like fungi when 
development is arrested. The character of the alvine evacu- 
ations must be scrutinized, and the tone of the digestion 
brought to its highest standard. Alkalies for acidity, prepa- 
rations of pepsine for atonic digestion, with some prepara- 
tion of iron when the acute febrile symptoms have subsided, 
with possibly bark and cod-liver oil internally, are remedies 
which have always to receive consideration. In many cases 
of debility and failing nutrition in infancy, I have found 
beneficial results to follow the wearing over the abdomen of 
a flannel bandage saturated with cod-liver oil. It is nasty, 
but if we can make the skin aid the weak digestion we should 
do so. If the child have reached seven months, it may han- 
dle strip after strip of rare roasted or broiled beef, and daub 
its face all over while sucking the A^talizing juices, on the 
assimilation of which so much may depend. The yolk of a 
soft-boiled egg, beef-tea, chicken and mutton broth, in such 
strength and quantity as may prove to be digestible in the 
individual case, should be tried. But above all, when the 
abscess is opened, and it is apparent that there remains only 
the gradual closure of its walls, and such repair of tissue as 



HYGIENE. 429 

depends directly on nature ratlier tlian art, then let the little 
patient be carried, if possible, away from the city to the sea- 
side or the mountain in summer, to the South in winter, to 
that place, in short, where the most invigorating influences 
from life in the pure and open air can be enjoyed to their 
uttermost. 

What a blessing it is for anxious parents to be able to 
command these influences for their children ! They are the 
privilege of wealth or competence, and an incentive to labor. 

Babies should he frequently weighed. — The influence of a 
proper supply of breast-milk on the development and weight 
of children at the breast is shown in the following table, 
which was prepared at my request during my last term of 
service, and according to my schedfile, by Dr. E. D. Hud- 
son, Jr., from the children in the wards, and the table offers 
an additional contribution to the imperfect data on which 
the semeiology of infancy is based. 

There is no test so accurate and so subtle as the balance 
for appreciating the standard and condition of babies. It is 
better that every child should be accurately weighed at birth, 
and that it should be weighed from time to time during the 
first year of life, even though it seem to be improving satis- 
factorily. But in all cases of faulty nutrition it is indispensa- 
ble for deciding positively whether assimilation be satisfac- 
tory or not. 

"When we consider that the little baby must grow from 
the weight of six or eight pounds at birth to that of nineteen 
to twenty-five in the first year, we have clearly before us the 
emphatic evidence that it cannot afford to lose time and op- 
portunity, and that all guess-work, and handling, and opin- 
ions, should give way before the impartial judgment of the 
balance. 

Why it is, I do not know, but some of my patients, and 
many of the Jewish faith, are unwilling that their children 
should be weighed. 



430 



OBSTETEIC CLIOTC. 



EEPOET OX THE 

WEIGHT, PULSE, AND RESPIRATIOX OF INFANTS, 

AND OF THE 

ITODiraNG INPLUENCE OP ALDTENTATIOX AND STATE OP HEALTH, 
By E. D. HUDSON, Jr., M.D., 

Junior Assistant Surgeon, Bellevue Hospital, April, 1867. 



Age. 



^^j^* Weight Time of 

birth, "o^- d^'y- 



Awake 

or 
Bleeping. 



Martin Bums 

Michael Kelly 

Ellen McNamara . . . 

Paul Friese 

Helena Paul 

James Larkins 

Mary J. Foster 

Joseph Began 

Thomas Eagan 

Annie Mellen 

Minnie Sherman . . . . 
Joseph Simmons . . . 
Margaret Seeley — 
Katy McFadden..., 

Willie Schmidt 

John Eussells 

Mary Brannan 

OwenDa\'is 

Ellen Macauly 

Patrick Henry 

James Cronin 

Harriet Eagan 

John J. Foster ..A 

Mary J. Hampton.. 

Carrie Cornell 

Annie Moore 

Mary Ann Dowlan. , 
Francis Goodman.. 

Geo. F. Nelson 

Albert Jones 

Sarah McKee 

Mary E. McBonald. 

John W. McBonald 

Francis Murray 

Joseph Beare 

Mary Nolan , 

Mary Merwin 

Thomas Johnston. , 

John Conway 

John Hughes 

Francis Garvis 

Edward Ho we 

Mary Hughes , 

John McGay 

John Kelly 

Patrick Welch 



4 w. 4 d. 
2 m. 

1 m. 4 d. 
w. 4 d. 

2 m. 

4 "w. 

2 w. 2 d. 

5 w. 

1 m. 9 d. 
4 w. 

3 w. 

2 w. 2 d. 

6 w. 

3 w. 
6 w. 

1 w. 
11 d. 

2 w. 
1 m. 

4 m. 

1 m. 12 d. 
Im. 3d. 

Im. 



Breast. 
B"t&B'e 
B't&B'e 
Breast. 
B't&B'e 
Breast. 
Breast. 
Breast. 
Breast. 
Breast.* 
Breast. 
Breast. 
Breast. 
Breast. 
B't&B'e 
Breast. 
Breast. 
Breast. 
Breast. 
B't&B'e 
B't&B'e 
Breast. 

Breast. 

Breast. 
Breast. 
Breast. 
Breast. 
Breast. 
Breast. 
Breast. 
Breast. 

Bottle. 

Bottle. 

Breast. 

Breast. 

Breast. 

Breast. 

Breast. 

Breast.t 

Breast. 

Breast. 

Breast. $ 

Breast. • 

Breast. 

Breast. 

Breast. 



D'rhoea, 

Cough. 
BadD'a 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 
D'rhoea 

Good. 

Sickly. 

Good. 

Good. 

Good. 

Good. 

Good. 

Feeble 

Good. 
D'a and 
G"l Ery- 
sipelas. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Feeble, 

Good. 

Good. 
Good. 
Good. 
Good. 
Good. 
Good. 
Good. 
Good. 
Good. 
Good. 
G<»od. 
Good. 
Good. 



. oz. lb. 
8 



12 



— 11 
1212 

12| 7 



9 12 



4 7 

8 7 

- S 

8! 7 



815 

— 7 



6 12 
8 4 



5 2 



oz, 

7 1 p. M. 
1 IP.M. 

.30P.M, 
—I 4 p.m. 

4 3.30p.m. 
— I 1 p. M. 

4 3 p.m. 

8j 4 p.m. 

8 2.30p.m. 
12 3 p.m. 

4 3 p.m. 

— 11 A. M. 
11 :2.30p.m. 

11 A. M. 

3 p.m. 
4.30p.m. 

3 p.m. 

2 p.m. 

12 m. 
8,12.15 
110.45 
lIll.lS 

4 11.30 

15 11.30 

1312 

1211.30 

8ill.30 

911.45 

3,11.45 

— 10.30 
4 10.45 



9 10.45 



8 111 

5 8 10.15 

8 1211 
12 11.15 
1211.30 

— ;ii.3a 

— |ll.30 
8;i0.30 

1010.49 
4'10.45 

9 1210.15 

7 4ilO 

8 810 

8 7ill.45 



Sleep'g. 
Nurs'g. 
Awake. 
Awake. 
Sleep'g. 
Sleep'g. 
Awake. 
Awake. 
Awake. 
Sleep'g. 
Awake. 
Sleep'g. 
Nurs'g. 
Sleep'g. 
Nurs'g. 
Sleep'g. 
Sleep'g. 
Awake. 
Awake. 
Sleep'g. 
Nurs'g. 
Sleep'g. 



136 40 

124 52 
140,56 
132 40 
116 40 
120 40 
138156 

125 {40 
120 40 
128 52 
138 40 
124' 38 
140 1 36 
1.36' 40 

95 36 
160 54 
128 56 
120 56 
128 56 
12432 
132 40 
120 38 



Awake. 130 50 



Awake. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Awake. 
Awake. 



1124 44 

il28|40 
;i28:46 
124 40 
118 36 
120 36 
120 40 
120 52 



Awake. 154 



Nurs'g. 

Awake. 
Awake. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Nurs'g. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Sleep'g. 
Nurs'g. 
Sleep'g. 



140 



56 



132 58 

1.38 44 
140 40 
120 46 
124 40 
128 48 
120138 
1.36'46 
11252 
124 58 
112139 
108 38 
11644 



months' child. 



t Mother dead. 



X 7 months' child. 



CONCLIJSIOI^^S. 



431 



co:s"CLUsioxs and estimates deawit from the gen- 
eral TABLE {preceding page). 

I. 

Whole number of Infants in the Wards 46 

" Males 27 

" " " Females • 19 

46 

n. 

Number of Infants, age 1 week or less 9 

" " " " 1 -week to 2 weeks 11 

" " " " 2 weeks to 4 weeks 14 

" " " " 1 month to 4 months 12 

46 

in. 

Average of Weight at Birth Y !b 6 § 

Greatest Weight at Full Term 11 " — " 

SmaUest Weight at Full Term 5" 2" 

Weight of a Child born at seventh month 4 " 8 " 



lY. 

Aterage of Weighty Fulse, and Respiration at different Ages. 





Pulse. 


Eespiration. 


Weight. 


1 week 


125 

12YI 

126A 

12^- 


48f 
444 
45 

43A 




2 weeks c . . . 


2 weeks to 1 month 


1-h 
10-A- 


1 month to 4 months 







of Pulse and Eespiration AwaTce and Sleeping. 



Awake. . 
Sleeping. 



Pulse. 
131^ 
125^ 



Eespiration. 
491f 
43^ 



432 OBSTETEIC CLINIC. 

VI. 

Awrage Development per Month. 

Average Gain per Month on Breast 15^o 3 

" " " "Bottle 1-/0- " 

Of the 38 on the Breast— 

32 have gained a monthly average of , 1 lb 9| 3 

6 " lost " " 121 a 

Of the 8 on the Bottle— 

3 have gained ^^rS § 

5 " lost : SA " 

YII. 
Greatest Individual Gain per Month. 

On the Breast 4 15 

" Bottle 1 " 6i i 

YIIL 

Highest and Lowest Ohserved Pulse and Respiration in Health. 

(All taken during sleep.) 

Ptilse. Eespiration. 

Maximum. 160 58 

Minimum 112 34 



CHAPTER XYII. 

KYESTEINE. 

The following article was published in the New York 
Journal of Medicine^ about nine years ago, and represents 
my views at the present time. My friend, the late Dr. 
Hemy Yan Arsdale, made all the examinations with me, 
and the results represent our united study of the subject : 

The admitted difficulty of diagnosing many cases of preg- 
nancy has led to the examination of the urine in the hope 
that some one of its conditions might prove a reliable test. 

These researches date back to the fathers of medicine ; 
and Avicenna is reported to have noticed a cotton cloud-like 
deposit in the recent urine of pregnant women ; and by his 
descriptions of " ascending granules," has been understood to 
refer to the formation of a pellicle. 

The belief, though vague, became general, and allusions 
thereto can be found floating down the stream of popular 
literature. Thus in Boccaccio's " Decameron^^ a poor simple- 
ton hoaxed into the belief of his illness, is persuaded by his 
jesting friends to send some of his urine to a physician in 
the plot, who decides from its examination that the man is 
pregnant ! 

But beyond this, I am not aware that the subject was 

made a particular study before the year 1831, when I^auche, 

of Paris, submitted to the profession his views of a peculiar 

gelatine- albuminous ingredient, or product, found only in 

28 



434: OBSTETEIC CLINIC. 

the urine of pregnancy, and separated by rest alone, whicli 
has received the name of Kyesteine, or Kyjestine, derived 
from KvTjGtg ecjg. 

He is thus entitled to the credit of calling attention to a 
subject which needed elucidation, and which was entirely 
obscure. The number of observers since that time has been 
small, but important statements have been made, and now 
that our knowledge of the kidneys and then* secretions is so 
advanced, the question will probably be settled ere long. 

ISTauche remarked that when the urine passed by a preg- 
nant woman was placed in a glass vessel and allowed to 
stand, a cotton-like cloudy deposit first appeared ; when 
later on, specks, or oblong points, gradually increasing in 
number, became agglomerated on the surface of the liquid, 
and appeared on the sides of the vessel. Thus the surface 
soon became covered wdth a firm tenacious pellicle, which he 
considered to be peculiar to pregnancy, and an evidence of 
that state ; and believed to be distinguishable from pellicles 
formed on the surface of urine in other conditions of health 
and disease. 

Eguisier followed with a paper based on the examination 
of twenty-five cases, and concluded that it was an invariable 
accompaniment of pregnancy, and distinguishable from other 
pellicles formed on the surface of urine. He explained the 
presence of this peculiar ingredient as resulting from the ab- 
sorption of the amniotic liquid, and remarked that when it 
had disappeared, the urine from the same woman gave this 
appearance no longer. 

Golding Bird felt that the subject promised fairly enough 
to demand his attention, and he published, in 1840, views on 
the subject, which, in 1851, he saw no cause to modify. He 
procm^ed, in all, the urine of thirty pregnant women, which 
he examined in the manner recommended by his predeces- 
sors. The women were from the third to the last month of 
pregnancy, and in twenty-seven cases " copious fat-hke pelli- 
cles were obtained after a few days' exposure." The three 



KTESTEINE. 435 

women who did not ftirnisli the pellicle were suffering from 
inflammatory fever, and in one it appeared when the fever 
had left. By examining the mine of one patient he pro- 
nonnced her pregnant in spite of her positive denial, and his 
opinion proved to be correct. Under the microscope, Bird 
fonnd the pellicles to display nnmberless crystals of the triple 
phosphate, with beds of granular matter and tolerably regu- 
lar globular bodies. He believes the fatty appearance of the 
pellicle to be due to the presence of these crystals, though 
he recognizes some fatty matter. He does not allude to the 
presence of vibriones. 

Dr. Bird lays great stress on the evolution of a strong 
cheesy odor from the pellicle, or from the entire urine after 
its formation, and concludes, that if the urine of a pregnant 
woman affords a pellicle, after a few days' exposure, resem- 
bling the fatty scum of cooled mutton-broth, accompanied by 
a cheese-like odor, its presence will afford a strong corrobo- 
rative test of pregnancy, but not an entirely reliable one ; 
because, as he says, " we have, as yet, no right to assume, 
however probable it may be, that a caseous pellicle can ap- 
pear only when pregnancy exists." 

Dr. Elisha Kane has published an admirable paper on 
this subject, which will always be identified with the history 
of kyesteine. 

He examined the urine of eighty-five pregnant women, 
and ninety-four during lactation, a total of- one hundred and 
seventy-nine cases, presented in a tabular form. 

He considers that, although not unerring, it is among the 
most certain tests in the early period of pregnancy, and 
states, with confidence, his ability to give a pretty accurate 
opinion on the occurrence of pregnancy by the sole exami- 
nation of the urine. From the specimens of the urine of 
pregnancy, sixty-eight presented a well-marked pellicle ; and 
from those of lactation, thirty-two gave the characteristics 
of kyesteine. 

Dr. Kane, nevertheless, holds pretty closely to the views 



436 OBSTETEIC CLINIC. 

of Golding Bird, that this product is probably the result of 
the secretion of the rQammary glands, conveyed from the 
system by the kidneys ; and states that the occurrence of the 
pellicle, when the lacteal secretion is uninterrupted by fever, 
weaning, abscess, or other causes, is rare. Out of forty-eight 
such cases, but 'Q.ye presented the pellicle. He did not find 
the cheesy odor in the proportions stated by Bird ; and be- 
lieves some of the granular matters found under the micro- 
scope to be identical with colostrum, a view which has not 
received support. He examined the urine of sixteen unim- 
pregnated females, without being led into error. He admits 
the formation of a pelKcle in phthisis, vesical catarrh, uterine 
tumors, and metastatic abscesses, which might deceive the 
unpractised, but would not deceive him. His paper is well 
arranged, and bears marks of talent, industry, and enthusiasm. 

Dr. Letheby examined the m^ine of fifty pregnant women, 
obtaining kyesteine in forty-eight, and did not find it in the 
urine of seventeen non-pregnant. He found it in ten suck- 
ling women, decreasing as lactation advanced. He believes 
that the pellicle is not to be confounded with others, and 
compares the odor to putrifying beef. 

Becquerel examined the urine of three pregnant women, 
and nineteen recently delivered, and found nothing peculiar 
to pregnancy, and attributed the changes noticed by others 
to modifications undergone by the mucus. 

But filtration has not been found to alter the appearances 
of the urine, which are, moreover, similar in the cases where 
it has been drawn off with the catheter. Still, according to 
the statistics of Dr. Kane, Becquerel should have found some 
of the characteristics of kyesteine in about seven of his cases. 
Dr. Stark, of Edinburgh, examined more than sixty speci- 
mens of the urine of pregnancy, and propounded, as the re- 
sult of his labors, that there exists a proximate principle, or 
substance, sui generis, forming a connecting link between 
the gelatinous and albuminous principles, which he proposes 
to designate by the term " gravadine." He considers that 



KTESTEmE. 437 

tliis substance is presented under the microscope, in the form 
of globules, of a whitish hue ; perfectly circular and trans- 
parent, and reflecting an opalescent hue when light was 
thrown on their sides, or transmitted. He considers that the 
coloring matter resides in their external envelopes ; and that 
the pelhcle so often alluded to results from the decomposition 
of these globules. They were present in all of his speci- 
mens ; and he states that, by due attention to them and to 
the formation of the pellicle, you can give an opinion by 
the tenth week of pregnancy, provided that you can then 
hear the placental souffle, notice enlargement of the abdo- 
men, and mark the changes in the areola. 

He denies the importance of the cheesy odor in the urine, 
so strongly insisted upon by Bird. 

One would suppose that, if the discovery of Dr. Stark were 
of value, it would be more reliable as a test. 

Dr. Golding, in his elaborate essay on the " Signs of Preg- 
nancy," concludes that the kyesteine pellicle is the only cer- 
tain test before the fifth month ; that it is uninfluenced by 
age, temperament, or number of pregnancy — that it is never 
absent clming all the period of pregnancy, though the same 
woman may sometimes furnish it, and sometimes not ; and 
that it disappears during lactation. 

Yanoni examined the urine of one hundred and forty 
women, and found the peculiar pellicle unfailing, save in the 
urine of one woman ^ve months pregnant. When led to 
doubt the value of other signs, he would be guided by this 
test. 

Dr. Yeit instituted a series of experiments at the Lying- 
in Hospital of Halle — observing the changes in the mine of 
forty-eight pregnant women, four non-pregnant, and ten men. 

He arrived at the conclusion that kyesteine was not a prod- 
uct of pregnancy, nor peculiar to that state, and attaches 
no value to it as a test. 

He speaks of the myriads of vibriones which, with the 
triple phosphates, he considers to constitute the pelhcle ; and 



438 OBSTETRIC CLmiC. 

alludes to tlie greater degree of alkalinity in the urine of 
pregnancy. 

Zimmermann considers kjesteine to result from the forma- 
tion of these vibriones in the lowe,r strata of the liquid, which, 
rising to the top, unite with triple phosphates, amorphous 
phosphates of lime, and urates of ammonia, to form the pel- 
licle, thus ignoring the existence of any ingredient peculiar 
or confined to the pregnant state. 

Eegnault considers the nitrogenized matters found in all 
urine to be vastly in excess in the urine of pregnancy, deny- 
ing that it contains any new principle. He attributes the 
pellicle to the vibriones and triple phosphates. The change 
is effected principally by the action of oxygen. 

Indeed, experiments are not wanting to show the effect 
of atmospheric air on the development of these vibriones, not- 
withstanding the fact of their having been voided in some 
cases of extreme vitiation of the constitution. 

Simon found the pellicle to consist of amorphous matter 
with opaque specks, vibriones in movement, and triple phos- 
phates ; while monads appeared at a later date. 

Such being a fair resume of the literature of the subject, 
it is evident that the question is far from settled, and without 
any other desire than to form opinions for our guidance, we 
determined to examine the appearances for ourselves, — and 
believing that many of those who had preceded us had relied 
on too small a number of cases, we desired to test a great 
number of specimens, and made tabular records of over one 
hundred and fifty-three^ having examined over one hundred 
and sixty. In order that we should be less exposed to the 
chances of deception or error, we obtained most of the urine 
from women who applied at my office in the ISTew York 
Lying-in Asylum, of which I was then Eesident Physician, 
for a ticket, which would enable them to be attended in 
their labor by the district physician of the Asylum — though 
we did. not adopt this plan until we had satisfied ourselves 
that the appearances did not seem to be affected by the 



KYESTEINE. 439 

time of day wlieu tlie urine was passed ; in other words, 
that the " urina sanguinis " was not necessary to the experi- 
ment. 

The urine thus obtained was exposed to the proper tem- 
perature in shallow, wide-mouthed glass vessels, holding an 
ounce or more, and covered witli a label referring to the 
number of the case in the record. A portion of eacb speci- 
men was tested with heat and nitric acid — with litmus-paper 
— often with acetic acid, as well as boiled with liquor potas- 
sse, contained in bottles free from lead. 

The daily changes were regularly noted until they could 
be almost foretold by us in many cases, and tlie microscope 
was brought to bear on every specimen many times. 

We thought, and still think, that these observations should 
have been made more extensively on the urine of the earliest 
months of pregnancy, and on the urine of lower animals ; 
but the drudgery of the task and the result of our researches 
have not stimulated us to continue further. 

It seemed to us desirable to notice whether the micro- 
scope could reveal any " globular " or other bodies peculiar 
to pregnancy, and to this part of the examination Dr. Yan 
Arsdale gave the most faithful and unwearied attention. 

J^ow, while the urine collected and thus exposed fur- 
nished us with pellicles after various intervals of time, yet did 
these pelhcles differ greatly from each other in appearance 
and modes of formation. While one-sixteenth of the whole 
number failed to present a pellicle, still their characteristics 
are readily referable to certain types. 

To begin with the changes which were the most satisfac- 
tory as coinciding with those on which the value of kyesteine 
as a test of pregnancy reposes : 

First day. — Cloud-like deposit, like very thin blue-milk 
dropped in the urine ; or, like some fuzzy cotton carefully 
scraped. 

Second day. — Shining specks in the urine, and commen- 
cing film on the sm^face. 



440 OBSTETRIC CLIKIC. 

Third day. — Film forming well, clieesy odor. 

Fourth day. — Film very distinct, tenacious, about a line 
in thickness, concave on its upper surface, " glistening like 
spermaceti," lighter in color than the rest of the urine, which 
has, however, assumed an opaline hue. The white specks 
which preceded the formation of the pellicle are very dis- 
tinct, and adherent to the sides of the glass. Brilliant crys- 
talline specks on the surface. Cheesy odor very distinct. 

Seventh day. — This state of things has continued, and 
the pellicle is now beginnimg to break up. It commences 
to crack and separate, showing a darker color through its in- 
terstices. 

The microscope displays now, as it has done some days 
since, vibriones and monads, disporting themselves in 
a dark amorphous mass studded with opaque points, and 
having imbedded within it very numerous and well-formed 
crystals of the triple phosphate, but no globular bodies 
whatsoever, either in the sediment, pellicle, or intermediate 
strata. 

I^ow, could such appearances be found in the urine of 
pregnancy, and the urine of pregnancy alone, the need of 
the profession would be supplied ; but the proportion of such 
classical specimens was small, and the cheesy odor rarely 
present, even in specimens equally well marked. 

"We have seen a pellicle, resembling the foregoing descrip- 
tion in every single particular (saving the cheesy odor), form 
on the urine of a healthy woman, suckling a child four 
months old, and which required aJl the milk that the well- 
supplied breasts of its mother could famish. 

A female servant in the asylum had been troubled with 
dysmenorrhoea. She would be faiat, hysterical, very trou- 
blesome to deal with, and alarming [herself, and all the 
women around her, when her turns came on. I examined 
the uterus at one menstrual period, drew off her urine with 
the catheter, and exposed it as usual. 

Hers passed through the changes described, and presented 



ETESTEINE. 44:1 

a well-marked, thick, tenacious, fatty scum on tlie surface, 
studded with cream-colored spots, differing in no respect 
from numbers of our best-marked specimens. The micro- 
scope displayed the appearances described above. I know 
that this woman had not been pregnant for two years, and 
she remained under my close observation for many months 
subsequently, and therefore these appearances occurred in 
the mine of pregnancy, in the urine of uninterrupted lacta- 
tion, and in the mine of an unimpregnated female at a period 
of time amply remote from a previous pregnancy. 

Neither of these last two specimens gave the cheesy odor, 
but we soon learned that it was too infrequent to serve as a 
test of the mine of pregnancy. 

In three specimens from pregnant women presenting the 
same appearances, and undergoing similar changes, we might 
find the cheesy odor in one, the odor of putrescent beef in a 
second, and an unspeakable odor in the tliird. 

A very common variety of pellicle, and one that we ac- 
quired the habit of foretelling with great certainty, is apt to 
fonn on the urine of anaemic, anxious-looking women. It is 
generally of a pale color, and contains a larger admixture of 
vaginal mucus. The changes occurring in this kind of urine 
are very much as follows: the specimen becomes rapidly 
opaline in color, without the preceding whitish specks, 
twenty-four hours being, for the most part, more than suffi- 
cient for the transformation ; and by that period of time the 
surface has assumed a glazed appearance from the presence 
of a film, which, as it does not differ in color from the urine, 
might escape observation, unless a probe or sharp-pointed 
instrument were passed through it ; when an even, regular, 
and slightly tenacious film would be detected. This would 
remain for variable periods, sometimes for more than a 
week, becoming thicker and better formed, and giving the 
best examples of the pellicle resembling the fatty scum of 
cooled mutton-broth. 

Xow, in this kind of urine we were able to foretell the ap- 



442 OBSTETEIO CLINIO. 

pearance of yibriones and monads at an earlier period of 
time tlian in any otlier, they being visible before tbe crystals 
of the triple phosphate. 

In some of these specimens, while the change in color 
jnst referred to and the microscopical appearances were the 
same, the pellicle would resemble a thin layer of collodion, 
adhering tightly to the centre, and sinking with the evapo- 
ration of the liquid. 

We have not observed the monads to appear at a later 
period than the vibriones, as a general rule. 

Again, some specimens of urine would give the cotton- 
like, cloudy deposit for the first day, and by the expiration 
of that time, the surface would be studded with brilliant 
crystals of the triple phosphate, as though diamond-dust had 
been sprinkled there. 

This urine was generally alkaline from the beginning, 
and when we had recognized this appearance, we no longer 
anticipated the opaline change in color, nor any of the pelK- 
cles that have been described. 

These points would increase in number, become agglom- 
erated, and form a pellicle, indeed — but one dry, irregular, 
and pointed, which broke up, and fell to the bottom as the 
others did. 

Another pellicle fi^equently met with, was one forming 
rapidly, dry and dark-looking, and rugous as though it had 
been blown with the breath and suddenly crisped. Under 
the microscope, vibriones and monads would first appear. 

A gentleman visiting my office one day, passed some 
water at my instance, which was exposed under the same 
conditions as the others. To om^ amusement, a pellicle, 
precisely resembling the last described, formed and lasted 
some time. 

This variety, however, while presenting the cotton-like 
deposit, does not present the opaque spots and bright oblong 
points seen in others. 

Other specimens obtained from pregnant women would 



KYESTEmE. 443 

present a dense, turbid deposit. Tlie urine would deepen in 
color, and, after the usual time, from two to five days, an 
un adherent, clotted, dirty-looking pellicle would cover about 
two-thirds of the surface, presenting, as usual, the vibriones, 
monads, and triple phosphates. 

Indeed, so far as the appearances of the pellicles went, 
we found no type distinctive of the ui-ine of pregnancy ; for 
while the mine of women, whom we knew to be pregnant, 
furnished us with entirely difierent pellicles, under exposure 
to the same conditions of atmospheric temperature and light, 
we found even among our limited number of specimens from 
the urine of unimpregnated females, and men, that pellicles 
would form similar to those on the urine of pregnant women. 

With regard to the microscopic appearances, we can say, 
that so uniform were the appearances of vibriones, monads, 
and triple phosphates, that we soon ceased to allude to them, 
otherwise, than by their initials. 

While the great proportions of our specimens were acid, 
we yet rarely met with crystals of uric acid. Urates of am- 
monia were not infrequent on the first day of exposure, and 
we have some cases recorded as presenting the urates of soda, 
and the oxalates of lime were often seen. 

We had hoped that Stark's views might bear the test of 
examination, and that it might be possible to observe with 
the microscope some appearance which should serve as a test 
for pregnancy. 

Nearly one hundred and sixty specimens of the urine of 
pregnant women have been thus examined, without the dis- 
closure of any thing peculiar to the urine of pregnancy. 

Torulse were not unfrequently met with, and generally, 
without the stems, present in diabetic urine, and this led to 
om- examination of the urine for sugar, which was done by 
boihng a portion with liquor potassse, kept in bottles freed 
from lead. 

If this test should be considered at all reliable, the pro- 
portion of such cases was found to be large. 



444 OBSTETEIO CLINIC. 

While engaged in these examinations, a specimen of m-ine 
"\;vas brought bj a student of medicine, Mr. Bedell, for ex- 
amination. It was fi.'om a patient of his, suspected of preg- 
nancy. 

"WTien I saw it (in the evening), it had already stood some 
days, and a thin, even, light-colored pellicle had formed — 
lighter in color than the subjacent urine, and commencing 
to crack. The urine was not albuminous, and the micro- 
scope disclosed numerous small globular bodies^perfectly 
circular ; regular in size ; whitish in color ; transparent in the 
centre, and opalescent on the edges — floating in the pellicle, 
sediment and intermediate strata ; acetic, hydrochloric, sul- 
phuric and nitric acids did not affect them, nor were they 
changed by succussions with ammonia, ether, and chloroform. 

In a word, they answered so fairly to the description by 
Stark of his " globular bodies," that we suspected the woman 
of being pregnant by all the laws of " Gravidine." This 
patient remained under the care of Mr. Bedell, who knows 
that she was not pregnant dm-ing all the time that she con- 
tinued under his observation. And as this was the only spe- 
cimen that presented appearances resembling the globules 
described by Dr. Stark, we have not been able to confirm 
his observations. 

One of om- specimens of mine from men presented ap- 
pearances answering pretty closely to Dr. Stark's description, 
but by the seventh day they had commenced to germinate. 

Conclusions. — In short, the result of om- labors but en- 
ables us to say, that we have seen nothing conclusive as 
to recognizable peculiarities in the m-ine of pregnancy. We 
think that there is nothing positive in its indications, and 
that its appearances can scarcely even be called '"' corrobo- 
rative." 

We reached this conclusion slowly, yet without regret ; 
for we had no preconceived views to fm-ther, and only de- 
sired to marshal an array of facts which might speak to us 
for themselves. 



ge:^eeal ij^dex 



PAGE 

Abortion, the practice of, in this 

country, 383 

Abscesses in infants, the treatment 

of the exhausting effects of, 428 

resulting from pelvic cellu- 
litis, the question of opening 

promptly, 3*79 

pelvic fistulge from, 380 

Abscess, retro-pharyngeal, symp- 
toms and treatment of, 422 

Acid, benzoic, use of, in albumi- 
nuria, 36 

carbolic, as a preventive of 

infection in large hospitals, .... SQ^ 

mineral, use of, in albuminuria, 36 

phosphoric, use of, in albumi- 
nuria, 36 

tartaric, use of, in albumi- 
nuria, 36 

Albuminuria, dangers froro, may 
be developed only after parturi- 
tion, 11 

■ frequency of, in the puerperal 

state, 7 

in epilepsy, 129 

of pregnancy, prognosis of, . . 13 

physiognomy in, 30 

relations of, to pregnancy,. . . 10 

sources of error in estimating 

danger from, 11 

Alimentation, table of the modify- 
ing influence of, in infancy,. . . . 430 



PAGE 

Anasarca, tendency of, to relieve 
the danger of urasmia, 15 

Anaemia, a concomitant of eclamp- 
sia, 76 

certain to follow recovery 

from severe post-partum hemor- 
rhage, 28'7 

Anassthesia, in facilitating version, 342 

Anaesthetics, indications for the 
employment of, in removing pla- 
centa, 232 

Anodynes, in post-partum hemor- 
rhage, 235 

Apocynum cannabinum, use of, in 
eclampsia, 35 

Appearance, external, not neces- 
sarily suggestive of pelvic de- 
formity, 257 

Atmosphere of hospitals a source 
of unfavorable complications 
after confinement, 367 

Baptism, preliminary, 317 

Barnes's dilators, suggestion as to 
use of, in preventing prolapse of 

funis, 108, 170 

use of, in controlling hemor- 
rhage from placenta praevia, 145, 150 

in the treatment of rigid os, . 1 70 

Bellevue Hospital, report of ex- 
amination of urine of pregnant 
women admitted to, 7 



446 



GENERAL INDEX. 



PAGE 

Binder, obstetric, the use and ap- 
plication of, after labor, 239 

Birnbaum's statistics of results in 
cases of deformed pelvis, 352 

Blood-letting, topical, from uterus, 384 

Blot's perforator, 324 

Blunt-hook, the, 328 

Breast-milk in infancy, importance 
of a proper supply of, 429 

Bright's Pisease, symptoms of, du- 
ring pregnancy, may disappear 
after parturition, 12 

Brow and face presentations, re- 
marks on, 206 

Brow presentations very fatal to 
foetus, 208 

should endeavor to convert 

them into posterior fontanelle or 
frank-face presentations, 212 



Carbolic acid as a preventive of 
infection in large hospitals,. . . 367 

Catheter, choice of, for use with 
the parturient woman, 401 

introduction of, between the 

membranes, for producing ute- 
rine contractions, 186 

Causes of undue elevation of the 
fundus uteri after delivery,. . . . 229 

Cellulitis, a frequent accompani- 
ment of chronic affections of 
the pelvic organs, 367 

pelvic, abscesses resulting 

from, 379 

risk of, in surgical treatment 

of diseases of women, 366 

sometimes not traceable to 

any known cause, 372 

Cephalic version, methods of per- 
forming, 342 

Cephalotribe, the, 326 

Cervix, dilated and dilatable, im- 
portance of distinction between, 156 



PAGE 

Cervix uteri, management of rigid, 157 
Change of scene, for patients sub- 
ject to puerperal mania, 131 

Chloroform in puerperal eclampsia, 63 
safety of, in obstetric opera- 
tions, ■ . . . . 64 

Cold, application of, in post-partum 

hemorrhage, . . . „ 227 

Colpeurynter, the, in hemorrhage, 150 
Compression of funis, dangers 

from, 405 

Confinement in asylums, of pa- 
tients afflicted with puerperal 

mania, 131 

Congestion of brain without extra- 
vasation as a cause of death. Dif- 
ficulty of determining by post- 
mortem appearances, 208 

Contraction of band of circular 
muscular uterine fibres in de- 
layed labor, 197 

Contractions, uterine, methods for 

inducing, 178 

Convulsions, puerperal, varieties 

of, 56 

Cord around neck, danger from, 

very slight, 406 

knots in, , , 408 

pressure on, a source of dan- 
ger, 408 

Cranioclast, Simpson's 327 

Craniotomy forceps, the, 327 

rarely if ever justifiable where 

child is alive, 204 

Crotchet, the, in embryotomy, .... 325 
Cupping, advantages of, over vene- 
section, in eclampsia, , . , , 76 

use of, in albuminuria, 36 

Dangers of version, 347 

to foetus from obstruction of 

circulation in the cord, 406 

Death of the foetus, difficulties at- 
tending the proof of, 315 



GENEEAL INDEX. 



MT 



PAGE 

Deformity of pelvis admits of vary- 
ing results in successive preg- 
nancies, 253 

increasing frequency of, in 

this country, 252 

may not be evident from ex- 
ternal appearances, 257 

Delayed and obstructed labor, the 
proper time for operating in,. . . 276 

Delay in performing obstetric op- 
erations, tendency to evil results 
from, 277 

Delivery of head through pelvic 
brim by forceps, difficulty of,. . 278 

Diaphoretics in the prophylaxis of 
puerperal eclampsia, 34 

Diet and hygiene, value of, in 
infancy, 427 

Difficulties attending the proof of 
the death of the foetus, 315 

Difficulty in estimating the size of 
the foetal head, 205 

Diet in the prophylaxis of puer- 
peral eclampsia, 34 

Dilatation of cervix uteri may fail 
to produce uterine contractions, 179 

manual, in the treatment of 

rigid OS uteri and cervix, 176 

Diuretics in the prophylaxis of pu- 
erperal eclampsia, 34 

Douche, the directions for the 
use of, 158 

the, in rigid os and cervix. . . . 158 

the, objections against use of, 158 

Eclampsia, puerperal, more com- 
mon in primipara3, 13 

prophylaxis of, 33 

treatment of, 63 

venesection in, 75 

Elaterium, use of, in eclampsia, . . 35 
Electric and galvanic currents in 

amenorrhoea, 191 

as galactagogues, 191 



PAGE 

Electric and galvanic currents for 

the induction of labor, 191 

Embryotomy, 314 

choice of instruments in, ... . 324 

Engagement of head in the brim 
by altering the mother's position, 285 

by external manipulation, . . . 281 

Epilepsy, infrequency of, in albumi- 
nuria, 129 

Epileptics not specially liable to 

puerperal eclampsia, 128 

Ergot, danger to the child from 

the use of, 194 

and forceps, choice between, 

in delayed labor, 194 

for multiparas at close of labor, 237 

in the induction of labor, ... 194 

in post-partum hemorrhage, . 227 

Ether-spray, the, in post-partum 

hemorrhage, 227 

Ether, sulphuric, preference for, in 

cases of cardiac disease, 68 

use of, in puerperal eclampsia, 64 

Exercise in the open air and sun- 
shine, importance of, in treat- 
ment of diseases of women,. ... 374 
Expulsion, spontaneous, the rarity 
of, in transverse presentations, . 346 

Faeces, necessity for examination 
of, in cases of puerperal mania, 133 

Fillet, the difficulty of passing it 
around the posterior thigh, 319 

Fistulae from pelvic abscesses, ... 380 

Foetus, dangers to, from compres- 
sion of circulation in the cord, 406 

death of, difficulties attend- 
ing the proof of, i 315 

Food, indications for the use of, in 
puerperal mania, 132 

Forceps, advantage of a sliding 
pivot on, 301 

appHcation of the anterior 

blade, 312 



M8 



GENEEAL INDEX. 



PAGE 

Forceps, application of, in the brim, 298 

best employed as tractors, . . 300 

choice, uses, and applications 

of, 287,300 

dangers from the appUcation 

of, within the brim, 298 

introduction of, within the 

cervix uteri 287 

lacerations from, more apt to 

be vaginal than perineal, 307 

position of patient in applica- 
tion of,. . .-. 312 

requisites for a, adapted to 

the great majority of cases,. . . 303 

tractive force which can be 

advantageously used with, 305 

or version, question of, in 

prolapse of the funis, 413 

Forceps vs. version, Hennig's statis- 
tics, 353 

Fracture of limbs in version, or 
original pelvic presentations.. . 364 

Frank-face presentations, manage- 
ment of 217 

Franke's dinner-pill, use of, in al- 
buminuria, 35 

Fundus uteri, undue elevation of, 
a sign of danger, 229 

Funis, prolapse of, 409 

dangers from compression of, 405 

Galvanic and electric currents for 
the induction of labor, 191 

Gastralgia in albuminuria relieved 
by pressure on the os uteri 116 

Grenser's statistics of results in 
cases of deformed pelves 352 

Hand, the, in utero, as a means of 
controlling post-partum hemor- 
rhage, 227 

Head, engagement of, in the brim 
by altering the mother's posi- 
tion 285 



PAGE 

Head, engagement of, in the brim, 
by external manipulation, 281 

foetal, diflficulty in estimat- 
ing the size of, 265 

Heart-sounds, inaudible, not neces- 
sarily proof of death of foetus, . . 315 

sudden cessation of, indicates 

danger to foetus, 321 

Hemorrhage, after contraction of 
the uterus, causes and treat- 
ment of, 233 

ante-partum, certain cases 

successful either with or with- 
out operative interference, 143 

fatal post-partum, may not 

flow from the vagina, 230 

post-partum,. 223 

post-partum, dangers and 

treatment of, 225 

post-partum, predisposition 

to, may be induced by one at- 
tack 237 

secondary post-partum, caus- 
es of, 237 

the use of the colpeurynter 

in, 150 

the use of the tampon in,. . . 149 

unavoidable, reasons why 

prompt iaterference may some- 
times be delayed in, 148 

Hennig, statistics of version vs. 

forceps, 353 

Hospitals for women, necessity for 

more, 383 

Hospital atmosphere, the cause of 

unfavorable compUcations after 

confinement, 367 

Hot-air baths, use of, in eclampsia, 35 
Hydrargyri, chloridum corrosivum, 

the use of, in eclampsia, 34 

chloridum mite, the use of, 

in eclampsia, 34 

Hygienic treatment in diseases of 

women, 374 



GENERAL INDEX. 



44:9 



PAGE 

Hygienic treatment of infants, im- 
portance of, 427 

Induction of labor as a prophy- 
laxis in albuminuria, 38 

Inflammatory complications in the 
surgical treatment of diseases 
of women, 366 

Importance of chemical and micro- 
scopical examinations of urine 
in pregnancy, 11 

Incision of the os rarely neces- 
sary during labor, 298 

Iodide of potassium in the treat- 
ment of pelvic cellulitis, 373 

Isaacs, Charles E., M. D., tribute 
to the memory of, 14 

Jactitation, a frequent symptom 

in albuminuria of pregnancy, 18 
Jalap, use of, in eclampsia, 35 

Kyestein, and the urine of preg- 
nancy, 433 

unrehability of microscopi- 
cal characters of, in urine of 
pregnancy, 443 

Labor, delay of, produced by tonic 
circular contraction of uterine 
muscular fibres, 197 

delayed, demands pelvic 

measurements, 257 

delayed, and obstructed, the 

proper time for operating in, . . 276 

induction of, by electric and 

galvanic currents 191 

induction of, by introduction 

of a catheter between the mem- 
branes, 186 

induction of, by medicines,.. 194 

induction of, by puncture of 

the membranes, 193 

29 



PAGE 

Labor, induction of, by separation 
of the membranes, 191 

induction of, Rodenberg's 

method, 187 

premature, reasons for induc- 
ing in special cases, 49, 163 

Laceration from forceps, vaginal 
more common than perineal, . .. 307 

Leeching the uterus, cautions in,. 386 

Liquor amnii, drain of, may fail to 
produce uterine contractions,.. . 184 

escape of, usually followed 

by uterine contractions, 193 

premature discharge of, fol- 
lowed by tedious labor, 198 

Lusk, W. T., M. D., analysis of 
experience of German authori- 
ties in version as an elective 
operation, 351 



Maina, puerperal, prognosis of, . . . 130 

puerperal, treatment of, ... . 130 

treatment chiefly expectant, 134 

Manipulations, external, in engag- 
ing head in the brim, 281 

of the uterus in controlUng 

post-partum hemorrhage, 227 

Mattel's forceps, 280 

Measurements, pelvic, cannot be 
made accurately by hand alone, 265 

pelvic, necessity for accu- 
racy of, 257 

pelvic, should always be made 

in cases of delayed labor, 257 

Membranes, may be separated with 
advantage in hastening labor, . . 191 

necessity of preserving the 

integrity of, until the cervix is 
dilated, 193 

puncture of, in the induction 

of labor, 193 

Mercurials, prophylactic power of, 
in eclampsia, 34 



450 



GENEEAL INDEX. 



Mercurials, unfortunate results 
from the use of, in albuminuria, 33 

Methods for inducing uterine con- 
tractions, 1'78 

Metritis, chronic, general plan of 
treatment in, 385 

risk of, in surgical treatment 

of diseases of women, 366 

Necessity for a careful examination 
of placenta and membranes after 
delivery, 231 

Nitrogenous food, the use of, in al- 
buminuria, 36 

Obliquity of the uterus, an obstacle 
in labor in a case of deformity, 166 

Obstetric binder, the use of the, 
after labor, 239 

operations in deformed pel- 
ves, 241 

Os uteri, incision of during labor 
rarely necessary 298 

treatment of rigidity of, by 

Barnes's dilators, , lYO 

by manual dilatation, 176 

by the douche, 158 

by sponge or other tents, ... 175 

Pelvimeter, Dr. J, Lumley Earle's, 

use of, 260 

Pelvimetry, 263 

liability to error in, 264 

Pelvis, deformity of, increasing fre- 
quency of, in this country, 252 

deformity of, admits of va- 
rying results in successive preg- 
nancies, 253 

deformed, Birnbaum's, Hen- 

nig's, and Grenser's statistics of 

results in, 352 

Perforator, Blot's, 324 

the introduction of the, 328 



Perforators, choice of, for embry- 
otomy, 324 

Peritonitis, risk of, in surgical 
treatment of diseases of women, 366 

Pessaries, tolerance of, when im- 
properly used, 370 

use and choice of, 369 

Physiognomy, the, of albuminuria, 30 

Placenta, inflation of, by Dalton's 
method, , . 113 

and membranes, necessity for 

a careful examination of, 231 

method of removal, 332 

portions of, retained, a cause 

of undue elevation of fundus 
uteri, 229 

prsevia, alternatives in a case 

of, 147 

Podalic version, methods of per- 
forming, 341 

Position of foetus in utero appre- 
ciated by examination of its 
hand, 344 

of patient in forceps opera- 
tions, 312 

of patient in the treatment of 

hemorrhage, 233 

Post-partum hemorrhage, 223 

reasons for desiring uterine 

contractions in, 326 

treatment of, : 227 

Potassae, bitartras, in albuminuria, 35 
Potassium, bromide of, use of, in 

albuminuria, 36 

Predisposition to post-partum hem- 
orrhage induced by one attack,. 237 
Pregnancy an exciter of albumi- 
nuria, 10 

clinical peculiarities of, 10 

Presentations, brow, apt to be fatal 

to foetus, 208 

change of, during labor,. ... 50 

face, with chin posteriorly, 

dangers from, 218 



GENEEAL INDEX. 



451 



PAGE 

Presentations, frank face, manage- 
ment of, 21*7 

pelvic, fracture of limbs in,.. 364 

transverse, the rarity of spon- 
taneous expulsion in, 846 

Primiparae, greater liability of, to 

puerperal eclampsia, 13 

Prodromata, in albuminuria, 104 

Prognosis, as to time in a labor, 

should always be guarded, 179 

in albuminuria of pregnancy, 13 

Prolapse of funis, 409 

difficulties of repositing the 

cord in cases of, 415 

use of porte-cordon in, 412 

Prophylaxis of puerperal eclamp- 
sia, 33 

Pugh, Benjamin, his recommenda- 
tions in cases of pelvic presen- 
tations, 222 

Pulse, condition of, in puerperal 

mania, 132 

weight, and respiration in in- 
fancy, table of, 430 

Purgatives, in the prophylaxis of 
puerperal eclampsia, 34 

Report of examination of urine of 
pregnant women admitted to 
Bellevue Hospital 7 

Respiration, weight, and pulse in 
infancy, table of, 430 

Restoratives and warmth in the 
treatment of hemorrhage, 234 

Retro-pharyngeal abscess, in in- 
fancy, symptoms and treatment 
of, 422 

Retroversion of uterus in preg- 
nancy, 393 

Ritgen's forceps, 280 

Rodenberg's method of the induc- 
tion of labor, 187 

Russian balhs, use of, in albumi- 
nuria, 36 



PAGE 

Saratoga waters, in albuminuria,. . 35 
Scanzoni's statistics in version,. . . 351 

Simpson's cranioclast, 327 

Sphincter ani, absence of contracti- 
bility of, in foetus, not necessari- 
ly a sign of death, 315 

Sponge-tents in the treatment of 

rigid OS, 175 

use of, followed occasionally 

by cellulitis, 378 

Steadying of the head against the 
brim in delivery by forceps, .... 279 

Tampon, the, in uterine hemor- 
rhage, 149 

Tents, sponge, or others, in the 
treatment of rigid os, 175 

Thomas, Prof. T. G., method of 
treatment of prolapse of the 
funis, 418 

Topical abstraction of blood from 
the uterus, 384 

Transfusion in hemorrhage, 236 

Turkish baths, use o^ in albumi- 
nuria, , 36 

Undue elevation of the fundus 
uteri a sign of danger 229 

Urine, importance of a free secre- 
tion of, in parturition 15 

importance of testing the, in 

pregnancy,, 11 

necessity for examination of, 

in cases of puerperal mania, 133 

necessity for ascertaining the 

quantity passed, 387 

of pregnancy, 433 

unreliability of microscopical 

appearances of, 443 

tendency of, to become alka- 
line in pregnancy, 12 

Uterus, obliquity of, an obstacle to 
labor in a case of deformity, ... 166 

retroversion of, in pregnancy, 393 



452 



GENERAL INDEX. 



PAGE 

Venesection in eclampsia, 7 3 

Version, an elective operation in 

many cases, ; 342 

by external manipulation, . . . 347 

dangers of, 347 

general considerations, .... 341 

two kinds, 341 

experiences of German au- 
thorities, as an elective opera- 
tion in contracted pelvis, 351 

fracture of limbs in, 364 

in deformed pelvis, as an 

elective operation, 348 

Version or forceps, the question of, 
in prolapse of the funis, 413 



PAGE 

Version vs. forceps, Hennig's sta- 
tistics, 333 

Warmth and restoratives in the 
treatment of post-partum hem- 
orrhage, 234 

Weight, pulse, and respiration in 
infancy, table of, 430 

Why tonic uterine contraction is 
desirable in post-partum hemor- 
rhage, 226 % 

Zuydhoek's method of induction 
of labor, 187 



INDEX OF CASES. 



PAGE 

Abortion; metritis; hypertrophy 
of the uterus, 382 

Abscess pelvic, opening into the 
peritoneal cavity, ............ 380 

Albuminuria and Bright's kidney. 31 

hydro-nephritis of one kid- 
ney; distended ureter; arach- 
nitis, : 42 

induction of labor, 109 

induction of labor ; mania ; 

recovery; subsequent history,. . 115 

intra -uterine hydrocephalus ; 

child born ahve, = . . . . 105 

miscarriage ; jactitation, 2*7 

secretion of urine very mark- 
edly diminished ; rigid cervix ; 
Barnes's dilators ; douche ; still- 
bom child with syphilitic liver ; 
mild diphtheria and laryngitis 
subsequent to confinement, .... 3 

without eclampsia ; early rup- 
ture of membranes ; rigid os ; 
incision of cervix ; chloroform ; 
forceps ; uterine fibrous tumors ; 
death, 18 

Ante-partum hemorrhage ; rota- 
tion of head before engaging in 
the brim ; forehead presentation 
converted into that of posterior 
fontanelle, 284 

Arm in the vagina; head above, 
to the right ; child dead ; per- 
forator; brow had originally 
presented, 333 



Arm presentation; cephalic ver- 
sion ; child supposed to be dead ; 
no reflex movements ; foetal 
heart inaudible ; meconium pres- 
ent in great quantity in the dis- 
charges ; child subsequently 
born alive, , 323 

Arrest of head by promontory of 
sacrum, , 274 

Breech presentation ; paralysis of 
sphincter ani coexisting with 
foetal heart sounds : fillet after 
death of child, 31Y 

Bright's disease; convulsions in 
sixth month of pregnancy ; pre- 
mature labor induced with 
Barnes's dilators, 106 

disease ; death four days 

after delivery; no convulsions; 
peritonitis, 1 

Brow presentation; forceps and 
version failed in consequence of 
tonic circular contraction of a 
band of uterine muscular fibres ; 
perforator ; crotchet, 198, 200 

Cellulitis (erysipelatous) in a new- 
born child ; incisions, 426 

of abdominal wall in a virgin, 3 7 7 

pelvic, unconnected with the 

puerperal state ; rapid recovery, 371 

pelvic, and suppuration fol- 
lowing sponge-tents, 378 



454 



INDEX OF CASES. 



PAGE 

Chloroform, alarming symptoms 
from the use of, 65 

Compression of cord ; pelvic pre- 
sentation ; arrest of head ; de- 
livery of child by traction on 
lower jaw, 403 

of cord the cause of foetal 

death in a cephalic presentation, 404 

Contracted conjugate diameter in 
a primipara ; forceps, .... .245, 243 

— — conjugate diameter ; tonic 
contraction of uterine fibres cir- 
cularly ; failure of forceps ; im- 
possibiUty of version; craniot- 
omy, 203 

outlet ; arrest ; forceps ; per- 
foration, 331 

pelvic brim ; arrest ; forceps ; 

vesico-vaginal fistula, 273 

pelvic brim ; forceps, 274 

Convulsions, hysterical ; hemiple- 
gia, 58 

Cord around neck ; transverse po- 
sition of head ; child still-born, 404 

six times around the neck ; 

delivery with forceps for sake 

of the child, 407 

Cystitis; peri-cystitis and peri- 
nephritis in a virgin, 375 

Deformed pelvis ; albuminuria ; 
craniotomy after failure of for- 
ceps and version ; use of Simp- 
son's cranioclast, and Lumley 
Earle's pelvimeter ; pneumonia 
and metritis,. 259 

pelvis ; breech presentation ; 

perforation ; convulsions ; re- 
covery, 185 

pelvis ; ergot ; forceps, 195 

pelvis ; forceps ; death from 

perforation of uterus by sacral 
promontory, 267 

— — pelvis ; premature labor ; un- 



PAGE 

usual difficulties in the induc- 
tion, 179 

Delayed labor; forceps; facial 
paralysis of child; recovery 
after convulsions, 299 

Dysuria from aphthous ulceration, 393 

Eclampsia, puerperal, 53, 103, 116 

puerperal ; albuminuria ; 

douche ; forceps withiti the cer- 
vix, 288 

puerperal ; cardiac disease ; 

oedema of lungs ; forceps ; death 
of mother subsequently from 
suppression of urme ; death of 
child, 15 

puerperal ; chloroform ; ca- 
thartics; emetic; venesection; 
death, 98 

puerperal ; chloroform ; for- 
ceps, 100 

puerperal ; chloroform ; cup- 
ping, 89 

puerperal ; chloroform ; cup- 

pmg ; forceps, . . - 86 

puerperal ; douche ; forceps ; 

delivery through a moderately 
dilated cervix, 289 

puerperal in the eighth 

month ; extraordinary family 
history ; rigid cervix ; douche ; 
dilators ; forceps, 290 

puerperal; induction of la- 
bor ; forceps ; Barnes's dilators, 39 

puerperal ; induction of pre- 
mature labor ; recovery, 44 

puerperal ; post-mortem Cae- 
sarian section; child found 
dead, 14 

puerperal ; profuse saUvation 

from mercurial purge, 34 

puerperal ; twins ; douche ; 

forceps; version; suppression 
of urine, ....,« 17 



INDEX OF CASES. 



455 



PAGE 

Eclampsia, puerperal; efforts at 
manual dilatation of cervix ; 
douche ; Barnes's dilators ; still- 
born putrid child delivered by 
traction, 2*7 

puerperal ; forceps ; manual 

dilatation of cervix, 100 

puerperal ; forceps, YS 

puerperal ; forceps ; chloro- 
form, 85 

puerperal; venesection; for- 
ceps, 79 

puerperal ; no albumen, .... 99 

puerperal ; urine free from 

albumen ; forceps, 80 

puerperal; twins; chloro- 
form ; cathartics ; cupping, 90 

puerperal, with mania ; death, 94 

puerperal ; venesection ; cups ; 

chloroform, 82 

puerperal ; venesection,. . . . YV 

puerperal ; venesection ; ca- 
thartics ; forceps, 84 

unyielding os ; douche ; in- 
cision ; forceps, 296 

puerperal, post-partum ; post- 
partum hemorrhage, 230 

puerperal, unconnected with 

renal disease ; consciousness not 
abolished ; chloroform ; douche, 56 

puerperal, in sixth or sev- 
enth month; induced labor; 
venesection ; douche ; purga- 
tives ; delivery with crotchet,. . 336 

puerperal ; death in subse- 
quent pregnancy, 37 

puerperal ; induction of labor, 122 

puerperal, in a multipara ; 

premature birth of a still-born 
putrid child, 45 

puerperal ; death before de- 
livery, 112 

puerperal ; death from apo- 
plexy, 114 



PAGE 

Eclampsia, puerperal, in first con- 
finement ; persistence of renal 
symptoms ; induction of prema- 
ture labor in a subsequent con- 
finement, 47 

puerperal ; douche ; dilators ; 

craniotomy, 124 

puerperal ; forceps, 32 

E|iilepsy ; puerperal mania ; death 

of child in convulsions, 127 

venesection ; confinement, . . 129 

Ether, sulphuric; alarming symp- 
toms from the use of, 66 

Face presentation ; rotation of 
chin to pubes with forceps,. . . . 219 

Fatty degeneration of foetus and 
placenta at term ; peculiar use 
of blunt-hook, 338 

of one-half of a double pla- 
centa in a case of twins, 340 

Feet and funis presentation ; still- 
born child, 413 

Fistula, urethro-vesical, 66 

Foot, hand, and funis presentation 
of a second twin ; commencing 
inversion of uterus, rectified by 
manipulation, 228 

Forceps above the brim, 280 

and lacerations of the va- 
gina; subsequent forceps de- 
livery of a living child, 307 

for arrest of head in the su- 
perior strait from extension of 
head ; manual efforts at flexion 
unavailing ; laceration of cervix, 293 
-- — for cessation of heart-sounds, 321 

for danger to child, 407 

for delay, 276 

for danger to child ; diflScult 

auscultation, 323 

for cord tightly around neck, 313 

still-born child; death of 

child and difficulty in delivery 



456 



IXDEX OF CASES. 



PAGE 

believed to hare been due to 
the encircling of the neck by 

the funis, 309 

Forceps for exhaustion of the moth- 
er; approximation of ischiatic 
spines ; liquor amnii colored 
Tvith meconium, 320 

for febrile symptoms in a 

puerperal fever epidemic, 275 

in an undersized brim ; rigid 

03 ; engagement of the head in 
the brim by external manipula- 
tion, 282 

in hngering labor twice ap- 

phed, 316 

in superior strait, 2 7-i 

for -wedging of head m supe- 
rior strait ; great tractive force ; 
perforator, 304 

and perforator for deformity 

of brim, 332 

and perforator ; oblique cra- 
nial presentation from left ute- 
rine obhquity, 36S 

in peritonitis ; tendinous band 

in vagina, , 20-i 

in puerperal fever ; bronchi- 
tis ; death from hemorrhage on 
the twelfth day after delivery,. . 237 

for tedious labor from rigidi- 
ty; advantage of touching the 
head and forceps blades through 
the rectum during dehvery 308 

Fracture of arm in dehvery ; for- 
ceps ; occipito-posterior presen- 
tation, 365 

forceps ; version for trans- 
verse presentation, 365 



Hemorrhage, repeated ante-par- 
tum ; induction of premature la- 
bor by sponge-tents, douche, 
and Barnes's dilators, 140 



PAGE 

Hemiplegia attending hysterical 
con-\Tilsions, 58 

History of successive pregnancies 
in a patient with contracted con- 
jugate, 254 

Impacted head ; forceps ; perfo- 
rator, 306 

Induction of labor with douche, 
dilators, and catheter, . . ..187, 189 

Labor, delayed ; forceps ; amylene, 75 

powerless, with change of 

position of foetal head, 74 

premature, induction of, with 

the douche; prolapse of funis, .. 159 

premature, induction of, in 

a case of deformity, 161 

premature, induction of, with 

Barnes's dilators, 172 

Locked face presentation; effects 
of manipulation ; forceps ; per- 
forator, 217 

Mania, puerperal,.. .134, 136, 137, 139 
ilovement of descent brought 
about by changing position of 
the mother ; forceps, 285 

Occiput pressed against linea ileo- 
pectinea ; rotating from left ace- 
tabulum to near right sacro-ihac 
synchondrosis, and made to en- 
gage by manipulation, 283 

Pelvic presentation of a child 
weighing fourteen pounds ; re- 
markably small nates ; delivery 
with blunt-hook, 821 

in an tmdersized pelvis; 

room singularly obtained for 
forceps, 281 



INDEX OF CASES. 



457 



PAGE 

Perforation in a case of contracted 
antero-posterior diameter of 
brim, 329 

Placenta prsevia, 143 

premature delivery at seventh 

month, 144 

Barnes's dilators ; forceps, . . 146 

foot and hand presentation ; 

prolapse of funis, 151 

Poisoning by infusion of stramo- 
nium, 60 

Post-partum hemorrhage, 230 

Powerless labor, with rigidity ; er- 
got ; forceps, 305 

Prolapse of funis ; autopsy of 
child ; intra-uterine ascites and 

hydrothorax ; apoplexy, 410 

of funis, 402, 417 

foot and head presentation ; 

forceps ; child dead before the 

operation, 409 

head presentation ; forceps, . . 409 

in a breech presentation,. . . 416 

Prof. Thomas's plan; for- 
ceps, 414 

Rachitis ; contracted outlet ; for- 
ceps, 251 

Retention of menses by imperfo- 
rate hymen; operation; death,. 387 

Retro-pharyngeal abscess in an in- 
fant, 420, 427 

Retroverted uterus, with ovaries in 
the cul-de-sac forbidding the use 
of pessaries, 368 

Retroversion of an hypertrophied 
uterus, with dangerous menor- 
rhagia ; benefit from pessary,. .. 370 

of impregnated uterus ; great 

accumulation of urine ; success- 
ful reposition ; recovery, 393 

of impregnated uterus, 400 

of unimpregnated uterus .... 398 



PAGE 

Rigid OS promptly dilated by the 
warm douche, 169 

treated with Barnes's dilators 

and douche ; contraction of cer- 
vix after withdrawal of dilator, . 173 

douche ; manual dilatation ; 

forceps, 177 

and lingering first stage ; 

douche ; forceps within the 
brim, 274 

Right fronto-iliac presentation ; 
death of child ; ergot ; crani- 
otomy, 215 

Rupture of uterus; presentation 
of brow, hand, and funis ; de- 
delivery by version and the 
crotchet ; recovery, 208 

anterior uterine obliquity ; 

brow presentation, 210 

patient died undelivered,. . . 213 

at its vaginal attachment ; 

forceps, 295 

removal of the placenta, and 

version ; perforator, S'A 

Shoulder and arm presentation ; 
cephalic version by external 
manipulation, aided by vectis 
and forceps, ineffectual to fix the 
head ; podahc version ; perfora- 
tor, 215 

Spontaneous expulsion by cephalic 
version of the second twin pre- 
senting originally in a trans- 
verse position, 346 

Syncope after labor, 68 

Tedious labor ; ergot ; forceps, ... 195 
forceps ; novel views of ute- 
rine hemorrhage, 235 

Transverse presentation ; cephalic 
version ; contracted brim ; death 
of child from premature respira- 
tion 249 



458 



mDEX OF CASES. 



Twins ; contracted conjugate ; ves- 
ico-vaginal fistula after first la- 
bor cured by Dr. Emmet ; per- 
foration of both twins in this 
labor, 349 

in a pelvis three and a half 

inches conjugate diameter ; risk 
of locking heads prevented by 
manipulation, 220 

Unilocular ovarian cyst in the 
recto-vaginal cul-de-sac compli- 
cating parturition, and the cause 
of death 395 



Version; child dead; uterus dis- 
tended with gases, 344 



PAGE 

Version, for transverse presenta- 
tion of second twin, 345 

deformed pelvis; dwarf; for- 
ceps ; fever, 354 

deformity of antero-posterior 

diameter of brim ; forceps ; per- 
foration, 354 

forceps ; perforator ; contrac- 
tion of antero-posterior diameter 
of brun, , 356 

prolapse of funis ; transverse 

presentation, 357 

blunt-hook ; presentation of 

nape of neck and shoulder in a 
contracted pelvis, 359 

Vomiting, uncontrollable, in preg- 
nancy ; induction of premature 
labor; death, 16Y 



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